ATS Pulmonary Function Laboratory Manual

ATS Pulmonary Function Laboratory Management & Procedure Manual | 3rd Edition

APPENDIX 12.1  Sample Consent Form for Methacholine Challenge Test Procedure

The purpose of a methacholine challenge test is to determine the amount of airway irritability of a patient. You (or your child) will be asked to inhale a mist that contains different concentrations of a medication called methacholine or a placebo. The mist is produced by a device called a nebulizer, and you inhale the mist through a mouthpiece. Before the test begins and after each period of inhalation, you or your child will be asked to blow forcefully into a spirometer, a device that measures how much air you can blow out and how fast. The test will take approximately 60 minutes. The results from the test can help your doctor to decide which treatments are likely to work best for you or your child. Discomforts and Risks This test does not cause an asthma attack, but the inhalation of the mist may be associated with mild shortness of breath, cough, chest tightness, wheezing, chest soreness, or headache. Many patients do not have any symptoms at all. These symptoms (if they occur) are mild, last only a few minutes, and disappear following the inhalation of a bronchodilator medication, which we will give to you if indicated. The test is carried out in such a way that the dan- ger of a severe asthmatic reaction is minimized; however, there is still a very small possibility of severe narrowing of your airways. If this occurs, you or your child will be treated immediately and all medication necessary to treat you will be immediately available. Your signature below indicates you have read the above information and understand the purpose of the test and the associated risks. With this knowledge I agree to having this test performed on me or my child. ____________________________________ ______________ ____________________________ Patient or Guardian  Date Witness

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