PULMONARY
FUNCTION TESTS
– A REFRESHER
Khizer Hayat Khan
M Rahim Khan
York Teaching Hospital
INTRODUCTION
• Pulmonary function tests (PFTs) are non-invasive tests that show how
well the lungs are working.
• The tests measure lung volume, capacity, rates of flow, and gas
exchange
PURPOSE OF PFTs
• Diagnosis of symptomatic disease
• Screening of early asymptomatic disease
• Monitoring response to treatment
• Prognostication of known disease
TYPES OF PFTs
Spirometry
STANDARD PFTs Lung volumes
Gas transfer
Exercise oximetry
SPECIALIZED PFTs 6 minute walk test
Peak flow
CATEGORIES OF LUNG DISEASES
• PFTs help classify disease in following categories:
• OBSTRUCITVE | This is when air has trouble flowing out of the lungs
due to airway resistance. This causes a decreased flow of air
• RESTRICTIVE | This is when the lung tissue and/or chest muscles can’t
expand enough
• PULMONARY VASCULAR DISEASES |
SPIROMETRY
VALIDITY OF PFTs
• Evaluate acceptability & reproducibility
• Acceptability
• Good effort – a rapid increase in airflow at the start of exhalation
• Complete maneuver – at least 6s of exhalation ending up in plateau in flow
• Reproducibility
• All 3 FEV1 within 200ml of each other
• All 3 FVC within 200ml of each other
LUNG VOLUMES
LUNG VOLUMES
VOLUME AGAINST TIME
FLOW VOLUME LOOP
SPIROMETRY PATTERNS
• Normal
• Obstructive
• Restrictive
• Mixed
• Fixed upper airway obstruction
• Variable intra thoracic upper airway obstruction
• Variable extra thoracic upper airway obstruction
OBSTRUCTIVE SPIROMETRY
• FEV1:FVC ratio <70%
• FEV1 falls disproportionately greater than FVC
• Conditions such as Asthma, COPD, Bronchiectasis and CF
RESTRICTIVE SPIROMETRY
• FEV1:FVC ratio >80%
• Reduction of FEV1 and FVC
• Conditions such as ILD, pleural disease, NMD, Diaphragm dysfunction,
kyphoscoliosis, obesity and pregnancy
MIXED OBSTRUCTIVE/RESTRICTIVE
• FEV1:FVC ratio<70%
• Reduction in FVC
FIXED UPPER AIRWAY OBSTRUCTION
• Flow volume loop: flattening in both
inspiration and expiration
• Maximal flow rates limited
• Causes: tracheal/bronchial stenosis,
goitre, upper airway tumours
VARIABLE EXTRA THORACIC OBSTRUCTION
• Acceleration of air into the lung reduces
intraluminal pressures causing collapse at the
site of extra thoracic obstruction.
• Flattened inspiratory flow curve
• Normal expiratory flow curve
• Causes: vocal cord paralysis, airway burns,
glottic strictures
VARIABLE INTRATHORACIC OBSTRUCTION
• Decreased intrathoracic pressure splints
open the airway lumen at the site of
intrathoracic obstruction
• Normal inspiratory flow curve
• Flattened expiratory flow curve
• Causes: tracheomalacia, polychondritis,
low tracheal/bronchial tumours.
DIFFUSION CAPACITY OF CO
• (DLCO) is also known as the transfer factor for carbon monoxide or
TLCO
• It is a measure of the conductance of gas transfer from inspired gas to
the red blood cells.
DLCO
Conditions and physiologic states that alter DLCO
INCREASED DLCO
• Exercise
• Asthma
• Polycythaemia
• Pulmonary haemorrhage
DECREASED DLCO
• Emphysema
• ILD
• Anaemia
Low Normal/High
Assess FVC Assess FEV1/FVC Assess FVC
Normal/High
Assess TLC Normal lung
Assess TLC
mechanics
Variety of
Mixed Obstruction Restriction Assess DLC
explanations
Pulmonary
Assess DLCO Assess DLCO Normal PFTs
vascular disease
Chronic CWD/NMD/
Emphysema Probable ILD
Bronchitis/Asthma Obesity
PRACTICAL SCENARIOS
Pattern recognition
The major limitation of PFTs is how they are
interpreted
KEYPOINTS PFTs not standalone test
Requires organized approach
Identify and quantitate the abnormality
NORMAL
“Triangle over a semicircle”
FVC 4.68
FEV1 3.38
FEV/FVC = 3.38/4.68 = 0.72 or 72%
TLCO = KCO x VA
Don’t mix up TLC & TLCO!
TLC – Total Lung Capacity
TLCO – Transfer capacity of the Lung for Carbon monoOxide
(may also be referred to as DLCO – Diffusion Capacity of the Lung for Carbon
monOxide)
CASE 1
…53 year old gentleman with history
of asthma, complaining of dyspnea,
wheeze and cough. He had some relief
with inhaled therapy but remains
symptomatic. He is an ex-smoker of 22
pack year. I am concerned whether he
has developed COPD over the years
that he was smoking…
𝚫 350ml
𝚫 530ml
FEV1/FVC <70% OR <LLN? BRONCHODILATOR REVERSIBILITY
GOLD - <70% ≥200ml & ≥12% 𝚫 in either FEV1 or FVC
ATS - <LLN
Mild | FEV1 >=80%
SEVERITY OF AIRFLOW Moderate | 80%< FEV1 >=50%
OBSTRUCTION Severe | 50%< FEV1 >=30%
Very severe | FEV1 <30%
…..only if FEV1/FVC is obstructive
80-120% | Normal
<80% | Restriction 80-120% | Normal
>120% | Hyperinflation >120% | Air trapping
Airwary inflammation
Airway obstruction
Moderate severity
Positive bronchodilator response
Hyperinflation
Gas trapping
Slightly increased gas transfer
ASTHMA
CASE 2
…48 year old lady with COPD.
Current smoker of 30 cigarettes
a day. Remains short of breath
despite optimum treatment for
her COPD…
𝚫 0.05ml
𝚫 0.07ml
Severe airways obstruction
No reversibility
Hyperinflation
Gas trapping
Reduced transfer factor
EMPHYSEMA
CASE 3
...65 year old lady with
exertional shortness of breath
for 6 months. No other
respiratory symptoms. Hx of SLE
and recurrent UTIs. She is on
Prednisolone, Methotrexate and
Nitrofurantoin. She smoked 20
cigarettes a day for 31 years and
quit 18 years ago...
Restriction is graded by the decrement in FVC or TLC
SEVERITY OF % OF PREDICTED
RESTRICTION Mild 80-65%
Moderate 65-50%
Severe <50%
FVC
FVC
TLC
RV
RV
Restriction - Pulmonary or Extrapulmonary?
• Extrapulmonary causes of restriction
• Large pleural effusion/pleural thickening
• Neuromuscular disease
• Chest wall deformity
• Obesity
Restrictive lung disease
Moderate severity
Reduced gas transfer
ILD
CASE 4
… 60 year old lady symptomatic
with progressive shortness of
breath on exertion for several
months. No other respiratory
symptoms of note. She never
smoked and has no past medical
history of note. Her only
medications is hormone
replacement therapy…
SPIROMETRY GAS TRANSFER DIAGNOSIS
Reduced Emphysema
Obstructive Normal Chronic bronchitis
Normal / Increased Asthma
Reduced Intrinsic lung disease
Restrictive
Normal Extrapulmonary restriction
Anaemia
Normal Reduced
Pulmonary vascular disease
Restrictive/Normal Increased Pulmonary haemorrhage
Normal spirometry
Normal lung volumes
Reduced gas transfer
Pulmonary vascular disease
CASE 5
... 25 year old gentleman with
mild asthma well controlled
with PRN Salbutamol. Has been
symptomatic with dyspnea and
wheeze for a year. 2 years ago
he was involved in a road
traffic accident and was
intubated and ventilated. He
had a tracheostomy that was
removed 2 months after his
discharge from the hospital...
Don’t just look at the numerical values
EMPEY’S INDEX
FEV1 (ml) / PEF (L/min)
>10 suggests upper airway obstruction
The higher the ratio, the greater the obstruction
REFERENCES / USEFUL RESOURCES
• ERS Handbook of Respiratory Medicine 2nd edition
• Oxford Handbook of Respiratory Medicine, 3rd edition
• www.depts.washington.edu/uwmedres/Library/eLearning/Pulmonary
• Interpretting PFTs, Clevelenad Journal of Medicine
• Ruppel’s Mannual Of Pulmonary Function Testing, 11th edition
• UpToDate.com – Interpretting pulmonary function testing