Reflections of a paediatric pulmonologist: strategies for optimising lung function tests in preschool children

Abstract

In recent years, our clinical practice as paediatric pulmonologists has focused on refining strategies to optimise pulmonary function tests (PFTs) for preschool children, particularly those aged as young as 2 years and 5 months. This viewpoint reflects on our experience conducting over 7000 spirometry and impulse oscillometry (IOS) tests, sharing practical insights into achieving high success rates with young children. We emphasise the importance of creating a child-friendly, minimally stimulating environment, tailored communication using familiar and engaging language, and leveraging gamification and positive reinforcement. In particular, we highlight the use of role-playing as an effective engagement strategy, allowing children to teach a stuffed toy how to perform the test. Furthermore, we differentiate the approaches required for spirometry, which demands active cooperation, and IOS, which allows for tidal breathing and is more suitable for younger or less cooperative children. Through these strategies, we have achieved consistent, technically acceptable results in preschool-aged children, aligning with the latest standardisation guidelines. Our findings demonstrate the value of adaptability, patience and creativity in paediatric PFTs, suggesting that these approaches improve not only test accuracy but also the overall experience for both children and caregivers. Future research should further investigate these techniques to enhance paediatric pulmonary testing protocols.

Shareable abstract

Creating child-friendly environments and using gamification and role-playing significantly improve the accuracy and success of paediatric pulmonary function tests, reducing anxiety and enhancing cooperation for children as young as 2.5 years. https://bit.ly/3YbToSo

Introduction

Over the past 5 years, our clinical practice as paediatric pulmonologists has focused on optimising pulmonary function tests (PFTs) for children. Guided by the Standardization of Spirometry 2019 Update [1], which recommends starting with children aged 6 years and above, we initially concentrated on this age group and progressively adapted our methods to extend testing to younger children. We have successfully performed over 6500 spirometries in children aged 4 years and older, and more than 500 impulse oscillometry (IOS) tests, which require minimal patient cooperation and have been effectively used with children as young as 2 years and 5 months. We share practical insights and strategies developed from our experience with both spirometry and IOS. We have observed that many preschool-aged children achieve technically acceptable results, consistent with the latest standardisation guidelines [1]. By discussing our approach to creating child-friendly environments and using engagement techniques, we aim to offer a general guide for improving success rates in paediatric PFTs, even among very young children.

We distinguish between spirometry and IOS, as each test requires different approaches. Spirometry demands active cooperation with forced expiratory manoeuvres, while IOS can be performed during tidal breathing, making it a valuable tool for younger or less cooperative children [2]. In our practice, we often use IOS for children who are unable to meet the acceptability criteria for forced spirometry, particularly in the younger age groups. Data from a cross-sectional study in 3–6-year-old preschool children show that IOS is a useful tool in detecting pulmonary function abnormalities with minimal patient cooperation [3].

Our PFT team consists of a senior female paediatric pulmonologist and a male young paediatric pulmonologist, both of whom play integral roles in performing the tests. The senior doctor brings extensive experience in paediatric respiratory care, while the resident, who also works as an operator, excels in patient interaction, with patience being their strongest quality. This combination of experience and a patient-centred approach contributes significantly to the high success rates in obtaining technically acceptable PFTs, especially with preschool-aged children, who often require a methodical approach to feel comfortable and cooperate.

Creating an optimal testing environment

Creating a child-friendly testing environment is essential for the successful administration of paediatric PFTs. The testing room should be designed to be inviting without being overly stimulating. Our experience has shown that the room should contain a maximum of 3–5 playful elements to maintain the child's focus. In addition, avoiding mirrors in the room is crucial as they can distract children by allowing them to see themselves blowing into the devices. A calm environment reduces anxiety and enhances cooperation, as supported by evidence indicating that tailored environmental changes improve paediatric PFT outcomes [4, 5]. It is also important not to test immediately after an upsetting event, such as a medical procedure or vaccination, as the child may already be distressed, reducing their willingness to engage. Rushing through instructions without allowing the child to familiarise themselves with the equipment is another common mistake.

Effective testing strategies

Effective strategies are crucial for successful paediatric PFTs. One such strategy is the use of “successive approximations”, which involves gradually introducing the child to the testing process using familiar concepts. Starting with activities like measuring height and weight, which are common experiences for children, helps build comfort and trust. It is important to avoid abstract terms like “spirometry” and instead use phrases like “let's blow into some devices” or “let's play some computer games”.

Cognitive development from age 2.5 to 5 years shows considerable advancement in problem-solving, memory and understanding of abstract concepts. At 2.5 years, children can follow simple instructions and engage in early pretend play, but their attention span is short. By 3 years, they can ask more complex “why” questions and begin to follow multistep directions. At 4 years, they grasp concepts of time and counting, and participate in more imaginative role-play. By 5 years, children can handle multistep tasks, understand abstract ideas like rules and quantities, and sustain attention for longer periods [6]. These stages illustrate the progression in attention span, memory and problem-solving abilities, all of which are key when working with children on tasks like spirometry. The younger ages (2.5–3 years) require simpler, playful interactions, while older children (4–5 years) can handle more structured and complex instructions.

The use of familiar and age-appropriate language reduces anxiety and improves cooperation. By explaining procedures in a way that children can easily understand, we can create a more positive and effective testing experience [7, 8].

Gamification and positive reinforcement

Incorporating gamification and positive reinforcement into the testing process can significantly boost a child's engagement and cooperation by transforming the experience into a more enjoyable and motivating activity. For example, using digital simulation games or familiar narratives such as “The Wolf and the Three Little Pigs” encourages children to blow into the devices, while positive reinforcement, like starting the session with a “high five” and celebrating achievements with similar gestures, not only maintains their motivation but also ensures optimal performance throughout the test. These methods are further supported by studies showing that both gamification and positive reinforcement can enhance task performance and alleviate stress in paediatric patients, making these strategies particularly effective for improving the outcomes of paediatric PFTs [9–11].

Role-playing is an effective engagement strategy for younger children, where we often use a stuffed animal and encourage the child to take on the role of a teacher, demonstrating how to blow into the “trumpet” (figure 1), which not only reduces anxiety but also improves cooperation during medical procedures, as research suggests that playful, familiar interactions enhance a child's willingness to participate and follow instructions [4].

FIGURE 1.

A 3-year-old child is actively engaged in demonstrating the impulse oscillometry test process using a stuffed toy. In this approach, the child “teaches” the toy how to perform the necessary steps, such as a) measuring height, b) standing on a scale and c) even blowing into the spirometry device.

Discussion

Paediatric PFTs require adaptability and creativity to engage children effectively and reduce their fears. By using child-friendly environments, familiar language, gamification, positive reinforcement and role-playing, we believe we can help improve the testing process and contribute to a more positive experience for both children and their caregivers.

In conclusion, our experiences and the strategies detailed in this viewpoint provide a practical guide for improving paediatric PFTs. Future research could further explore the efficacy of these methods and develop additional techniques to enhance the testing experience for children.