Background: In March 2020, many elective medical services were canceled in response to the coronavirus disease 2019 (COVID-19) pandemic. The daily case rate is now declining in many states and there is a need for guidance about the resumption of elective clinical services for patients with lung disease or sleep conditions. Methods: Volunteers were solicited from the Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society. Working groups developed plans by discussion and consensus for resuming elective services in pulmonary and sleep-medicine clinics, pulmonary function testing laboratories, bronchoscopy and procedure suites, polysomnography laboratories, and pulmonary rehabilitation facilities. Results: The community new case rate should be consistently low or have a downward trajectory for at least 14 days before resuming elective clinical services. In addition, institutions should have an operational strategy that consists of patient prioritization, screening, diagnostic testing, physical distancing, infection control, and follow-up surveillance. The goals are to protect patients and staff from exposure to the virus, account for limitations in staff, equipment, and space that are essential for the care of patients with COVID-19, and provide access to care for patients with acute and chronic conditions. Conclusions: Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a dynamic process and, therefore, it is likely that the prevalence of COVID-19 in the community will wax and wane. This will impact an institution’s mitigation needs. Operating procedures should be frequently reassessed and modified as needed. The suggestions provided are those of the authors and do not represent official positions of the Association of Pulmonary, Critical Care, and Sleep Division Directors or the American Thoracic Society.

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BACKGROUND: Arterial puncture can be a painful procedure for many patients. This study investigates whether precooling of a puncture site with ice can reduce the pain associated with arterial puncture. METHODS: This was a stratified randomized controlled trial of a convenience sample of out-patients with a physician order for an arterial blood gas (ABG) test. The intervention group had a plastic bag of ice applied to their wrists for 3 min before drawing an ABG sample from the radial artery. The control group had an ABG sample drawn from the radial artery without the application of ice. Pain from the arterial puncture was measured with a 100-mm visual analog scale. RESULTS: Subjects pretreated with ice reported less pain from arterial puncture compared with subjects in the control group (mean visual analog scale 13.8 ؎ 16.9 vs 25 ؎ 23 mm, P ‫؍‬ .01; median visual analog scale 7 mm, interquartile range (IQR) 1.5-19 vs 20 mm, IQR 4.5-38.5 mm, P ‫؍‬ .01). Stratified analysis showed that visual analog scale pain scores were lower in the naive group when ice was applied (naive ice vs naive control: mean visual analog scale 11 ؎ 14.3 vs 26.5 ؎ 25 mm, P ‫؍‬ .02; median visual analog scale 5 mm, IQR 2-14.5 vs 20 mm, IQR 6.5-36 mm, P ‫؍‬ .02). Visual analog scale pain scores trended lower in the experienced group when ice was applied (experienced ice vs experienced control: mean visual analog scale 15.9 ؎ 18.9 vs 25.1 ؎ 22 mm, P ‫؍‬ .15; median visual analog scale 8 mm, IQR 0.5-26.5 vs 23 mm, IQR 3.5-40 mm, P ‫؍‬ .08). There was no difference in first-attempt success between groups (ice group: 85%, control group: 82.5%, P > .99). Only 3 subjects could not tolerate 3-min ice application. CONCLUSIONS: Ice application before arterial puncture is well tolerated and reduces procedure-related pain. (ClinicalTrials.gov NCT02065115).

Predicted values for pulmonary function tests differ significantly from the reference values used for many other diagnostic tests. Historically, simple equations using age, height, and sex were used to "predict" normal lung function. However, these multiple factors interact in complex ways to determine what the expected lung function values are in healthy subjects. Healthy individuals exhibit a wide range of variability for most pulmonary function variables, and this variability is not consistent across all age ranges. Recent analysis of large groups of healthy subjects has allowed the development of sophisticated prediction models that take into account not only variability but also skew that occurs as the lungs develop and mature. These modern reference equations provide uninterrupted expected values from early childhood, through adolescence and adulthood, and extending into the ninth decade. Modern equations use upper and lower limits of normal to offer a statistically robust means of defining who is within normal limits. Despite these advances, interpretation of pulmonary function test results has not been highly standardized, largely because interpretation depends on the reference equations used and, more importantly, how they are applied. This review discusses the strengths and limitations of using reference equations to interpret pulmonary function data in the context of research and clinical practice.

Spirometry testing plays an important role in the diagnosis and management of COPD and asthma in the primary care setting. Verifying the accuracy of the spirometer, using accurate patient demographics and appropriate reference equations, and ensuring the competency of testing personnel are key components of spirometry test interpretation. Spirometry testing plays an important role in the diagnosis and management of lung disease in the primary care setting. Spirometry interpretation should include an assessment of test quality and be based on sound statistical principals.