7.2 Patient Safety, Precautions & Adverse Events

Patient safety on the RPFT blueprint

Pulmonary function testing is elective for most patients—but it is not risk-free. Maximal forced maneuvers raise intrathoracic pressure, challenge tests intentionally provoke airway narrowing, arterial puncture breaches a vessel, and exercise or walk tests stress gas exchange and cardiovascular reserve. The NBRC DCO therefore scores patient safety explicitly under Domain II:

Chapter 5 covered infection-control materials and emergency equipment. This section is the procedural safety layer: what you screen for, what you prevent, what you watch for during the test, and when you stop.

Standard precautions and cross-contamination prevention

Every patient encounter uses standard precautions—treat all blood, body fluids, secretions, and contaminated surfaces as potentially infectious.

Core practices during PFT

1. Hand hygiene before and after each patient, after glove removal, and after contact with mouthpieces, filters, or blood.
2. Gloves for ABG, capillary sticks, handling blood-contaminated materials, and when contact with mucosa or non-intact skin is expected; additional PPE (eye protection, gown, respirator) when splash or airborne risk warrants it.
3. In-line bacterial/viral filters on spirometers and many breathing circuits; seat airtight; change per policy (typically between patients).
4. Single-patient mouthpieces, nose clips, and disposable circuit components when used; never “share” a used mouthpiece.
5. Surface disinfection of high-touch areas (chair arms, clipboards, stadiometer headpiece, pulse-ox sensors per IFU) with EPA-registered agents compatible with equipment.
6. Sharps safety for ABG: immediate disposal in puncture-resistant containers; no two-handed recapping.
7. Aerosol-generating procedures (nebulized challenge, sputum induction, heavy coughing): enhanced PPE, room ventilation awareness, and airborne precautions when TB or other airborne pathogens are suspected—delay or relocate testing per infection-control policy rather than aerosolize a contagious patient in an open bay.

Exam angle: a perfect FEV1 is worthless if the next patient inherits a contaminated circuit. II.A.18 includes choosing the right infection-control setup for the test ordered; II.B.18 includes actually applying it every time.

Cross-contamination risk map

Contraindications and relative risks by procedure type

The RPFT does not “always run the order.” II.A.18 means matching the test to the patient’s risk and knowing when to defer, modify, or escalate to the ordering provider.

Forced maneuvers (spirometry, peak flow, many volume and DLCO efforts)

Maximal forced expiration and inspiration transiently alter venous return, arterial pressure, and alveolar pressure. Relative contraindications / high-risk situations commonly taught (follow current ATS/ERS-style guidance and lab policy; lists evolve):

Relative does not always mean absolute never—it means pause, assess, document, and involve the ordering clinician when risk is elevated. Never coerce a dizzy, chest-painful, or frankly unstable patient into “just one more blast.”

Bronchial challenge (methacholine, mannitol, exercise/EVH-style pathways)

Challenge testing intentionally narrows airways. Additional safety layers:

• Confirm baseline spirometry is adequate and not already severely obstructed below lab stop thresholds.
• Screen for conditions that make induced bronchospasm dangerous (e.g., recent severe exacerbation, uncontrolled hypertension, pregnancy policies, inability to perform spirometry, known extreme hyperresponsiveness without clinical need).
• Have short-acting bronchodilator, oxygen, and monitoring ready before the first dose.
• Follow protocol stop criteria for symptoms and FEV1 fall; reverse with bronchodilator and observe recovery.

Arterial blood gas (ABG)

ABG risks are local and systemic:

• Contraindications / cautions at the site: abnormal modified Allen test (for radial), infection/burn over site, AV fistula, severe PVD in that limb, coagulopathy or thrombolysis (relative—balance urgency), patient refusal.
• Complications: pain, hematoma, arterial spasm, transient ischemia, infection, vasovagal syncope, rare serious ischemic injury.
• Safety performance (II.B.18): correct site selection, aseptic prep, steady technique, adequate pressure after draw, post-stick neurovascular checks, sharps discipline.

Adverse events: recognize and respond

High-cut items often embed an adverse event inside a procedure vignette. Know the pattern → immediate action pairs.

Syncope and near-syncope

Mechanism: forceful Valsalva-like efforts reduce venous return; hyperventilation; anxiety; standing still after maximal work.

Recognition: lightheadedness, tinnitus, visual gray-out, sweating, bradycardia or pallor, loss of postural tone.

Response: stop maneuvers immediately; protect from fall (support to chair or floor safely); supine or Trendelenburg if appropriate and no contraindication; monitor airway/breathing/circulation; oxygen if protocol/indicated; do not leave unattended; activate emergency response if unresponsive or delayed recovery; document and notify provider. Resume testing only if fully recovered and clinical judgment/policy allow—often testing is deferred.

Desaturation

Recognition: falling SpO2 (trust waveform quality), cyanosis, confusion, severe dyspnea out of proportion to effort.

Response: stop exercise/walk or high-risk procedure per protocol; position for comfort; supplemental oxygen per order/protocol; reassess SpO2 and clinical status; ABG/co-oximetry when SpO2 is unreliable or decisions are critical; escalate for refractory hypoxia.

Bronchospasm / severe airway obstruction

Recognition: wheeze, chest tightness, progressive FEV1 fall on challenge, accessory muscle use, falling SpO2, silent chest in severe obstruction.

Response: stop provocative agent; administer rescue bronchodilator per protocol; oxygen as needed; continuous monitoring; emergency activation for severe distress or poor response; do not send home until recovery criteria met.

Pneumothorax (rare but tested as risk awareness)

Maximal maneuvers are rarely associated with pneumothorax, especially with underlying bullous disease or recent instrumentation—but the RPFT must respect the risk.

Recognition: sudden unilateral pleuritic pain, acute dyspnea, asymmetric breath sounds (if assessed), desaturation, hemodynamic change in tension physiology.

Response: stop testing; urgent clinical evaluation; oxygen; emergency activation; do not continue forced maneuvers; arrange higher-level care. Documentation of sudden post-maneuver pain is a II.C.18 evaluation moment—not a “finish the FVC first” moment.

Other events to keep on the radar

• Chest pain / suspected ACS during exercise or heavy effort → stop, monitor, oxygen as indicated, emergency pathway.
• Hemoptysis after forceful cough → stop, assess, escalate.
• Hematoma or distal ischemia after ABG → pressure, assessment, escalate.
• Panic/hyperventilation → pause, calm coaching, reassess safety before restarting.

Stop criteria and emergency response readiness

Stop criteria should be predefined in lab policy and known cold by staff—not improvised mid-crisis.

Generic stop framework (adapt to test-specific ATS/ERS and lab SOPs)

Emergency readiness checklist (link to Domain I gear)

Before high-risk sessions (challenge, exercise, fragile patients, ABG in compromised patients):

1. Oxygen source checked and interface ready.
2. Bronchodilator available for challenge and reactive airways.
3. Pulse oximeter (and BP when protocol requires) applied with good signal.
4. Defibrillator/crash cart location and readiness known (Chapter 5.2).
5. Activation method clear (code button, rapid response, 911).
6. Staff roles understood—who coaches, who monitors, who calls for help.

II.C.18 includes deciding: Is the patient stable for discharge from the lab? Must a provider evaluate before leaving? Should remaining tests be cancelled? Releasing a still-wheezy post-challenge patient without recovery documentation is a safety failure even if numbers look complete.

Integrated safety scenario (exam mental model)

Order: spirometry + methacholine + ABG.

1. II.A.18 select: review history for recent MI, pneumothorax, hemoptysis, severe baseline obstruction, infection isolation needs; confirm challenge is appropriate; plan filters/PPE; stage BD, O2, oximeter.
2. II.B.18 perform: standard precautions; baseline spiro with filter; continuous observation for dizziness during forced efforts; challenge with stop rules; ABG only if still indicated and site safe; pressure post-stick.
3. II.C.18 evaluate: if FEV1 plummets and wheezing starts, stop challenge, treat, document recovery; if near-syncope after FVC, do not proceed to challenge the same hour; if SpO2 unreliable, do not ignore—fix sensor or get blood gas when clinically needed.

Practice connection

RPFT practice questionsPractice questions with detailed explanations

Bottom line: valid data never justify preventable harm. Standard precautions protect the next patient; contraindications and stop criteria protect this one; emergency readiness protects both when physiology turns against the plan.