Spirometry of Obstructive

Lung Diseases

Gamal Rabie Agmy, MD, FCCP

Professor of Chest Diseases, Assiut University
Pulmonary Disorders Effects on
Pulmonary Function
Obstructive:
Any process that interferes with air flow either
into or out of the lungs.
Large or small airways.

Restrictive:
 Any process that interferes with the bellows
action of the lungs or chest wall.
 Reduced lung volumes.
Differential Diagnosis:
COPD and Asthma
COPD Asthma
Onset In mid-life Onset early in life (often
Symptoms slowly childhood)
progressive Symptoms vary from day to day
Long smoking history Symptoms at night/early
Dyspnea during exercise morning
Largely Irreversible Allergy, rhinitis, and/or eczema
airflow limitation also present
Family history of asthma
Largely reversible airflow
limitation
Inflammatory Cascade in
COPD & Asthma
Measures of Assessment and
Monitoring of Asthma
Asthma diagnosis criteria:
Repeated variability in well-performed
spirometic values (increase in FEV1 or FVC).
Positive bronchodilator (BD) responses
(increase in FEV1 or FVC ⩾12% and 200 mL
from baseline).
Positive methacholine challenge (20% fall in
FEV1 at a dose ⩽8 μg/mL).
Objective lung function
measurements in Asthma
Spirometry:
▫ Forced Expiratory Maneuvers.
Exhaled Nitric Oxide.
Peak Flows.
GOLD 2013: Diagnosis of COPD
 Key Indicators to Consider COPD Diagnosis:
• SYMPTOMS
• Dyspnea-progressive (worsens over time and with exercise)

1 • Chronic cough
• Sputum

• HISTORY OF EXPOSURE TO RISK

FACTORS
• Tobacco smoke
2 • Smoke from home cooking/heating fuels
• Occupational dusts and chemical

• FAMILY HISTORY OF COPD

3

SPIROMETRY REQUIRED TO DIAGNOSE COPD

Presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow
limitation and thus of COPD.
Adapted from GOLD 2013
 Simple Interpretation of
Pulmonary Function Tests

Gamal Rabie Agmy, MD, FCCP

Professor of Chest Diseases, Assiut University
 Anatomy
 Lungs comprised of
 Airways
 Alveoli

http://www.aduk.org.uk/gfx/lungs.jpg
 The Airways
 Conducting zone: no
gas exchange occurs
 Anatomic dead
space
 Transitional zone:
alveoli appear, but are
not great in number
 Respiratory zone:
contain the alveolar
sacs
Weibel ER: Morphometry of the Human
Lung. Berlin and New York: Springer-
Verlag, 1963
 The Alveoli
 Approximately 300
million alveoli
 1/3 mm diameter
 Total surface area if
they were complete
spheres 80 sq.
meters (size of a
tennis court)

Murray & Nadel: Textbook of Respiratory

Medicine, 3rd ed., Copyright © 2000 W. B.
Saunders Company
 Mechanics of Breathing
 Inspiration
 Active process
 Expiration
 Quiet breathing: passive
 Can become active
 Pulmonary Function Tests
 Airway function  Lung volumes and
 Simple spirometry ventilation
 Forced vital capacity  Functional residual
maneuver capacity
 Maximal voluntary  Total lung capacity,
ventilation residual volume
 Maximal  Minute ventilation,
inspiratory/expiratory alveolar ventilation,
pressures dead space
 Airway resistance  Distribution of
ventilation
 Pulmonary Function Tests
 Diffusing capacity  Cardiopulmonary
tests exercise tests
 Blood gases and gas  Metabolic
exchange tests measurements
 Blood gas analysis  Resting energy
 Pulse oximetry expenditure
 Capnography  Substrate utilization
 Chemical analysis of
exhaled breath
Terminology

 Forced vital capacity

(FVC):
 Total volume of air that can
be exhaled forcefully from
TLC
 The majority of FVC can be
exhaled in <3 seconds in
normal people, but often is
much more prolonged in
obstructive diseases
 Measured in liters (L)
 FVC
 Interpretation of % predicted:
 80-120% Normal
 70-79% Mild reduction
 50%-69% Moderate reduction
 <50% Severe reduction

FVC
Terminology
 Forced expiratory volume
in 1 second: (FEV1)
 Volume of air forcefully
expired from full inflation
(TLC) in the first second
 Measured in liters (L)
 Normal people can exhale
more than 75-80% of their
FVC in the first second;
thus the FEV1/FVC can
be utilized to characterize
lung disease
 FEV1
 Interpretation of % predicted:
 >75% Normal
 Mild 70-75%
 Mod 50-69 %
 Severe 35-49%
 Very severe < 35%

FEV1 FVC
Terminology

 Forced expiratory flow 25-

75% (FEF25-75)
 Mean forced expiratory flow
during middle half of FVC
 Measured in L/sec
 May reflect effort
independent expiration and
the status of the small
airways
 Highly variable
 Depends heavily on FVC
 FEF25-75
 Interpretation of % predicted:
 >60% Normal
 40-60% Mild obstruction
 20-40% Moderate obstruction
 <20% Severe obstruction
 Acceptability Criteria
 Good start of test
 No coughing
 No variable flow
 No early termination
 Reproducibility
Changes in Lung Volumes in
Various Disease States

Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
 TLC
 TLC < 80% of predicted value = restriction.
 TLC > 120% of predicted value =
hyperinflation.
Lung Volumes
Spirometry
Spirometry should be performed after the
administration of an adequate dose of a short
acting inhaled bronchodilator (e.g. 400 ᶙg
salbutamol) to minimize variability.
A post-bronchodilator FEV 1/FVC <0.70
confirms the presence of airflow limitation that
is not fully reversible.
Where possible, values should be compared to
age-related normal values to avoid over-
diagnosis of COPD In the elderly.
Why Do We Need Spirometry
in COPD?
Spirometry is useful for:
Screen individuals at risk for pulmonary
disease.
Confirmation of COPD diagnosis.
Assessing severity of pulmonary dysfunction.
Guiding selection of treatment.
Assessing the effects of therapeutic
interventions.
Who Should Be Screened for
COPD?
Consider COPD, and perform spirometry, if any of these
indicators are present in an individual over age 40.
▫ Dyspnea that is progressive, usually worse with
exercise, and persistent.
▫ Chronic cough (may be intermittent and
unproductive).
▫ Chronic sputum.
▫ History of tobacco smoke exposure.
▫ Exposure to occupational dusts and chemicals.
▫ Risk factors.
▫ Exposure to smoke from home cooking and
heating fuels.
Spirometry Origin

Most basic of Pulmonary Function Tests

Clinical Tools Origin - Mid 1800' s
▫ John Hutchinson.
▫ Water-sealed spirometry to measure vital capacity
(VC).
Reasons for Performing
Spirometry
Diagnostic Purposes.
Monitoring Lung Disease.
Assessing Disability.
Spirometry

Spirometry with flow volume loops assesses the

mechanical properties of the respiratory system
by measuring expiratory volumes and flow rates.
▫ Maximal inspiratory and expiratory effort.
▫ At least 3 tests of acceptable effort are performed
to ensure reproducibility.
21st Century Spirometry

Measurements of:
Forced Vital Capacity (FVC).
Forced Expiratory Volume in one second
(FEV1).
Forced Expiratory Volume in six seconds
(FEV6).
Forced Expiratory Flow over various Intervals
(FEFx).
Peak Expiratory Flow (PEF).
Definitions and Terms
FEV1 - forced expiratory volume 1 - the volume of
air that is forcefully exhaled in one second.

FEV6 - forced expiratory volume 6 - the volume of

air that Is forcefully exhaled in six seconds.

FVC- forced vital capacity- the volume of air that

can be maximally forcefully exhaled.

FEV1/FVC- ratio of FEV1 to FVC, expressed as a

percentage.
Definitions and Terms

FEV/FVC- ratio of FEV6 to FVC, expressed as a

percentage.

FEF25 -75 - forced expiratory flow - the average

forced expiratory flow during the mid (25 - 75%) portion
of the FVC.

PEF- peak expiratory flow rate - the peak flow rate

during expiration.
Spirometry

Flow volume loops provide a graphic illustration

of a patient's spirometric efforts.
Flow is plotted against volume to display a
continuous loop from inspiration to expiration.
The volume versus time curve is a an alternative
way of plotting spirometric results.
The overall shape of the flow volume loop is
important in Interpreting spirometric results.
Acceptability & Repeatability
Acceptability

At least three (3) acceptable maneuvers

Good start to the test.
No hesitation or coughing for the 1st second.
FVC lasts at least 6 seconds with a plateau of at
least 1 second.
No valsalva maneuver or obstruction of the
mouthpiece.
FIVC shows apparent maximal effort.
Repeatability

Repeatability criteria act as guideline to

determine need for additional efforts.
▫ Largest and 2nd largest FVC must be within 150
mL.
▫ Largest and 2nd largest FEV 1 must be 150 mL.
▫ PEF values may be variable (within 15%).
If three acceptable reproducible maneuvers are
not recorded, up to B attempts may be recorded.
Spirometry Value
Spirometry is typically reported in both absolute
values and as a predicted percentage of normal.
Normal values vary and are dependent on:
▫ Gender,
▫ Race,
▫ Age, and
▫ Height.
Reporting Standards

Largest FVC obtained from all acceptable efforts

should be reported.
Largest FEV1 obtained from all acceptable trials
should be reported.
May or may not come from largest FVC effort.
All other flows, should come from the effort with
the largest sum of FEV 1 & FVC.
PEF should be the largest value obtained from
at least 3 acceptable maneuvers.
Results Reporting
Example
Report Format

Report should also include:

▫ Age on testing day.
▫ Height (standing without shoes).
▫ Weight (without shoes).
▫ Gender.
▫ Race or ethnic origin.
▫ Technologist comment section.
FEV1 Results for Asthma
FEV 1 Severity Results for Asthma
 At Risk for COPD
Spirometric classification of airflow limitation (in
patients with FEV1/FVC<0.70).

▫ GOLD 1 (Mild; FEV1 ≥80% predicted).

▫ GOLD 2 (Moderate; 50% ≤FEV1 <80% predicted).
▫ GOLD 3 (Severe; 30% ≤FEV1 <50% predicted).
▫ GOLD 4 (Very severe; FEV1 <30% predicted).

Adapted from GOLD 2013

Pre & Post Bronchodilator
Studies
B-Adrenergic aerosols are most common form
for testing.
Standardize.
▫ Drug.
▫ Dosage.
▫ Delivery Device.
Minimum of 15 minutes between pre and post
tests.
Pre & Post Bronchodilator
Studies: Withholding Medications
Pre & Post Bronchodilator
Studies: Interpretations
Determined based on improvement of FEV1.
Commonly expressed as Percent Change.

% Change = Post FEV 1 - Pre FEV1 x 100

Pre FEV1
Reversibility

Reversibility of airways obstruction can be

assessed with the use of bronchodilators.
> 12% increase in the FEV1 and 200 ml
improvement in FEV1
OR
> 12% increase in the FVC and 200 ml
improvement in FVC.
Spirometry
Asthma Challenge Testing

Spirometry can be used to detect the bronchial

hyperreactivity that characterizes asthma.
Increasing concentrations of histamine or
methacholine.
Patients with asthma will demonstrate
symptoms and produce spirometric results
consistent with airways obstruction at much
lower threshold concentration than normals.
Bronchial Provocation for Asthma
 Spirometry
Indications — Diagnosis
 Evaluation of signs and symptoms
- SOB, exertional dyspnea, chronic cough
 Screening at-risk populations
 Monitoring pulmonary drug toxicity
 Abnormal study
- CXR, EKG, ABG, hemoglobin
 Preoperative assessment
 Spirometry
Indications — Diagnosis
 Evaluation of signs and symptoms
- SOB, exertional dyspnea, chronic cough
 Screening at-risk populations
Smokers > 45yo
 Monitoring pulmonary drug(former
toxicity & current)
 Abnormal study
- CXR, EKG, ABG, hemoglobin
 Preoperative assessment
 Spirometry
Indications — Diagnosis
 Evaluation of signs and symptoms
- SOB, exertional dyspnea, chronic cough
 Screening at-risk populations
 Evaluation of occupational symptoms
 Monitoring pulmonary drug toxicity
 Abnormal study
- CXR, EKG, ABG, hemoglobin
 Preoperative assessment
 Spirometry
Indications — Prognostic

■ Assess severity

■ Follow response to therapy

■ Determine further treatment goals

■ Referral for surgery

■ Disability
 1-First Step, Check quality of the
test
1- Start:
*Good start: Extrapolated volume (EV) <
5% of FVC or 0.15 L
*Poor start: Extrapolated volume (EV)
≥5% of FVC or ≥ 0.15 L

2- Termination:
*No early termination :Tex ≥ 6 s
*Early termination : Tex < 6 s
2- Look at …………FEV1/FVC

< N(70%) ≥ N(70%)

Obstructive or Mixed Restrictive or Normal

3- Look at FEV1 To detect degree

Mild > 70%
Mod 50-69 %
Severe 35-49%
Very severe < 35%
4- Postbronchodilator FEV1/FVC

> 70% < 70%

asthma COPD
5- Reversibility test of FEV1

> 12%, 200 ml < 12% ,200 ml

Reversible (asthma) Ireversible (COPD)

6- Look at TLC

< 80% Mixed

≥ 80-120% Pure
obstruction
2- Look at …………FEV1/FVC
< N(70%) ≥ N(70%)

Obstructive or Mixed Restrictive or Normal

3- Look at FVC

≥ N(80%) < N(80%)

Normal or SAWD Restrictive

4-Look at FEF25/75
> 50% Normal < 50% SAWD
 Patterns of Abnormality

Obstructive low FEV1 relative to FVC, low PEF, low FEV1%FVC

R eco rd ed Pred icted SR % Pred
FEV 1 0.56 3.25 -5.3 17
FV C 1.65 4.04 -3.9 41
FEV 1 % FV C 34 78 -6.1 44
PEF 2.5 8.28 -4.8 30

Restriction low FEV1 & FVC, high FEV1%FVC

R eco rd ed Pred icted SR % Pred
FEV 1 1.49 2.52 -2.0 59
FV C 1.97 3.32 -2.2 59
FEV 1 % FV C 76 74 0.3 103
PEF 8.42 7.19 1.0 117 high PEF early ILD
low PEF late ILD
 Patterns of Abnormality

Upper Airway Obstruction low PEF relative to FEV1

R eco rd ed Pred icted SR % Pred

FEV 1 2.17 2.27 -0.3 96
FV C 2.68 2.70 0.0 99
FEV 1 % FV C 81 76 0.7 106
PEF 2.95 5.99 -3.4 49
FEV 1 /PEF 12.3

Discordant PEF and FEV1

High PEF versus FEV1 = early interstitial lung disease (ILD)
Low PEF versus FEV1 = upper airway obstruction
Concordant PEF and FEV1
Both low in airflow obstruction, myopathy, late ILD
 Common FVL Shapes
Flow

Volume

Normal Young or quitter Poor effort

Hesitation Knee Coughing

 12
Asthma
10

8 concave FV curve
Flow in L/s

intrapulmonary airflow obstruction

6

0
0 1 2 3 4 5 6
Litres
 Restrictive
12 F 19 yrs 1.64m
10 FVC 2.41 L -3.42 SR
FEV 2.41 L -2.62 SR
8 FEV% 100 +2.23 SR
PEF 5.55L/s -2.00 SR
6 F/P 7.2 RT 116 ms
Flow in L/s

2
0
0 1 2 3 4 5 6
-2 Litres
-4

-6
-8
 10
COPD

8
pressure dependent airways collapse
6

4
Flow in L/s

0
0 1 2 3 4 5
Litres
-2

-4

-6
 Poorly co-ordinated start

12
EV = large
Rise Time = 496 ms
10
Irregular shape
8
Poorly repeatable
6

2
Flow in L/s

0
0 1 2 3 4 5 6
-2 Litres
-4

-6

-8

-10
 Upper Airway Obstruction

6 Expiratory Age 40 yrs

FVC 3.52 L 0.84 SR
FEV1 3.0 L 0.74 SR
4
PEF 4.57 L/s -2.18 SR
FEV/PEF = 10.9
2
Flow in L/s

0
0 1 2 3 4 5 6
-2 Volume in Litres

-4
FEV1 in mls > 8
Inspiratory PEF in L/min
-6
 Upper Airway Obstruction
12
Male aged 62 Height 1.68m
10 R e co rd e d P re d icte d R an ge SR
FEV 1 2.23 2.94 2.1 to 3.8 -1.4
8
FV C 3.40 3.71 2.7 to 4.7 -0.5
FEV 1 % FV C 66 76 64 to 88 -1.5
6
P EF 2.85 7.81 5.8 to 9.8 -4.1
Flow in L/s

FEV 1 /P EF 13.1
4

0
0 1 2 3 4 5 6
-2 Volume in Litres

-4

-6
 Variable UAO

Inspiration Expiration
-ve +ve

-ve +ve

Extra-thoracic UAO Intra-thoracic UAO

worse on insp. worse on exp.
 Intra-thoracic UAO

12
Age 65 Female
FVC 2.97 L 1.3 SR
10
FEV1 2.26 L 0.6 SR
8 FEV1% 76% -0.1 SR
PEF 3.4 L·s-1 -2.5 SR
Flo w in L /s

6 F/P 11.1 RT 455 ms

0
0 1 2 3 4 5 6
-2 L ite rs

-4

-6

-8
 Upper Airway Obstruction
• Variable extrathoracic obstructions
1. vocal cord paralysis,
2. thyromegaly,
3. tracheomalacia, or
4. Neoplasm
• Large airways variable intrathoracic obstructions
1. tracheomalacia or
2. neoplasm
• Fixed obstruction
1. tracheal stenosis,
2. foreign body, or
3. neoplasm.
Obstruction, Restriction, Mixed
Variable Extrathoracic Upper
Airway Obstruction
Fixed Upper Airway Obstruction
 True Restrictive Disorders

Intraparenchymal
Chest Wall

Interstitial Infilterative Diffuse alveolar Pleural Skeletal Neuromuscular

Reduced TLC.FRC,RV,VC and normal to high FEV1/FVC

DLVA,Dlcoc or both DLVc parynhymal If normal Chest wall or neuromuscular

 Pseudorestrictive Disorders

Normally: IC/ERV=2-3/1

True restrictive: IC/ERV=<2/1

Pseudorestrictive: IC/ERV=6/1
 Pseudorestrictive Disorders

Asthma is a disorder characterized by increased reactivity of the

airways. Patients with asthma have recurrent or persistent airflow
obstruction, which is reversible either spontaneously or with
appropriate therapy. An obstructive pattern is most often present,
recognized by reduced forced expiratory volume in 1 s (FEV1), and
FEV1 to forced vital capacity (FEV1/FVC) or FEV1/vital capacity
(VC) ratio. Patients may have normal spirometry between attacks.
In some patients, the FVC may be reduced due to air trapping,
resulting in pseudorestriction on spirometry in the presence of
increased or normal total lung capacity (TLC), increased functional
residual capacity (FRC) and increased residual volume (RV). We
have reported 12 asthmatic patients with reduced VC and no
increase in RV, i.e., a true restrictive impairment [Gill et al. Chest
2012)
 Pseudorestrictive Disorders

Obesity:
*Early airway closure (low ERV & high RV)
*FRC is more reduced than TLC&VC
*Low FEF50% FEF75%, FEF25-75%,
,
 Pseudorestrictive Disorders

Neuromuscular Disease:
*FRC normal
*IC&ERV decreased
*Decreased TLC
*Increased RV
*A-aO2 gradient normal
*MIP&MEP decreased
 Pseudorestrictive Disorders

Asthma:
*FRC &TLC increased
*Improvement of FEV1&FVC with bronchodilators
*Positive bronchoprovacation test
*Increased diffusing capacity and DLco/VA
 Pseudopseudorestrictive

Patients with obstructive diseases who do not

complete expiratory effort of FVC. This may
lead to a below normal FEV1 and FVC with
pseudonormalization of ratio.
 Mixed Disorder

*Sarcoidosis
*Rhematoid
*Advanced IPF
*Bronchiectasis
*BOOP in smokers
 Obstructive Pattern

■ Decreased FEV1
■ Decreased FVC

■ Decreased FEV1/FVC
- <70% predicted

■ FEV1 used to follow severity in COPD

 Obstructive Lung Disease —
Differential Diagnosis

 Asthma
 COPD
- chronic bronchitis
- emphysema
 Bronchiectasis
 Bronchiolitis
 Upper airway obstruction
 Restrictive Pattern

 Decreased FEV1

 Decreased FVC

 FEV1/FVC normal or increased

 Restrictive Lung Disease —
Differential Diagnosis

 Pleural

 Parenchymal

 Chest wall

 Neuromuscular
Spirometry Patterns
 Bronchodilator Response

 Degree to which FEV1 improves with inhaled

bronchodilator

 Documents reversible airflow obstruction

 Significant response if:

- FEV1 increases by 12% and >200ml
 Request if obstructive pattern on spirometry
 Flow Volume Loop

 “Spirogram”

 Measures forced inspiratory and expiratory

flow rate

 Augments spirometry results

 Indications: evaluation of upper airway

obstruction (stridor, unexplained dyspnea)
Flow Volume Loop
 Upper Airway Obstruction

 Variable intrathoracic obstruction

 Variable extrathoracic obstruction

 Fixed obstruction
Upper Airway Obstruction
 Lung Volumes

 Measurement:
- helium
- nitrogen washout
- body plethsmography

 Indications:
- Diagnose restrictive component
- Differentiate chronic bronchitis from
emphysema
 Lung Volumes – Patterns

 Obstructive
- TLC > 120% predicted
- RV > 120% predicted

 Restrictive
- TLC < 80% predicted
- RV < 80% predicted
 Diffusing Capacity

 Diffusing capacity of lungs for CO

 Measures ability of lungs to transport inhaled gas

from alveoli to pulmonary capillaries

 Depends on:
- alveolar—capillary membrane
- hemoglobin concentration
- cardiac output
 Diffusing Capacity

 Decreased DLCO  Increased DLCO

(<80% predicted) (>120-140% predicted)

 Obstructive lung disease  Asthma (or normal)

 Parenchymal disease  Pulmonary hemorrhage

 Pulmonary vascular  Polycythemia

disease
 Left to right shunt
 Anemia
 DLCO — Indications

 Differentiate asthma from emphysema

 Evaluation and severity of restrictive lung

disease

 Early stages of pulmonary hypertension

 Bronchoprovocation

 Useful for diagnosis of asthma in the

setting of normal pulmonary function tests

 Common agents:
- Methacholine, Histamine, others

 Diagnostic if: ≥20% decrease in FEV1

 PFT Patterns

 Emphysema  Chronic Bronchitis

 FEV1/FVC <70%  FEV1/FVC <70%

 “Scooped” FV curve  “Scooped” FV curve

 TLC increased  TLC normal

 Increased compliance  Normal compliance

 DLCO decreased  DLCO usually normal

 PFT Patterns

 Asthma

 FEV1/FVC normal or decreased

 DLCO normal or increased

But PFTs may be normal  bronchoprovocation