Spirometry (meaning the measuring of breath) is the most common of the Pulmonary Function

Tests (PFTs), measuring lung function, specifically the measurement of the amount (volume)
and/or speed (flow) of air that can be inhaled and exhaled. Spirometry is an important tool used
for generating pneumotachographs which are helpful in assessing conditions such as asthma,
pulmonary fibrosis, cystic fibrosis, and COPD.

Parameters

The most common parameters measured in spirometry are Vital capacity (VC), Forced vital
capacity (FVC), Forced expiratory volume (FEV) at timed intervals of 0.5, 1.0 (FEV1), 2.0, and
3.0 seconds, Forced expiratory flow 25–75% (FEF 25–75) and Maximal voluntary ventilation
(MVV).[1] Other tests may be performed in certain situations.

Results are usually given in both raw data (litres, litres per second) and percent predicted - the
test result as a percent of the "predicted values" for the patients of similar characteristics (height,
age, sex, and sometimes race and weight). The interpretation of the results can vary depending
on the physician and the source of the predicted values. Generally speaking, results nearest to
100% predicted are the most normal, and results over 80% are often considered normal.
However, review by a doctor is necessary for accurate diagnosis of any individual situation.

Functional residual capacity (FRC) cannot be measured via spirometry, but it can be measured
with a plethysmograph or dilution tests (for example, helium dilution test).
Normal values for Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1)
and Forced Expiratory Flow 25–75% (FEF25–75%), according to a study in the United States
2007 of 3,600 subjects aged 4–80 years.[2] Y-axis is expressed in litres for FVC and FEV1, and in
litres/second for FEF25–75%.

[edit] Forced Vital Capacity (FVC)

Forced Vital Capacity (FVC) is the volume of air that can forcibly be blown out after full
inspiration, measured in litres. FVC is the vasic maneuver in spirometry tests.

[edit] Forced Expiratory Volume in 1 Second (FEV1)

Forced Expiratory Volume in 1 Second (FEV1) is the maximum volume of air that can forcibly
blow out in the first second during the FVC manoeuvre, measured in liters. Along with FVC it is
considered one of the primary indicators of lung function.

[edit] FEV1/FVC ratio (FEV1%)

FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC. In healthy adults this should be approximately
75–80%. In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV1 is
diminished because of increased airway resistance to expiratory flow and the FVC may be
decreased (for instance by air trapping in emphysema). This generates a reduced value (<80%,
often ~45%). In restrictive diseases (such as pulmonary fibrosis) the FEV1 and FVC are both
reduced proportionally and the value may be normal or even increased as a result of decreased
lung compliance.

[edit] Forced Expiratory Flow 25–75% or 25–50%

Forced Expiratory Flow 25–75% or 25–50% (FEF 25–75% or 25–50%) is the average flow (or
speed) of air coming out of the lung during the middle portion of the expiration (also sometimes
referred to as the MMEF, for maximal mid-expiratory flow). Expressed in liters per second it
gives an indication of what is happening in the lower airways. it is a more sensitive parameter
and not as reproducibles as the others. It is a useful serial measurement because it will be
affected before FEV, so can act as an early warning sign of small airway disease. In small airway
diseases such as asthma this value will be reduced, it could be more than 65% less than expected
value.

[edit] Forced Inspiratory Flow 25–75% or 25–50%

Forced Inspiratory Flow 25–75% or 25–50% (FIF 25–75% or 25–50%) is similar to FEF 25–
75% or 25–50% except the measurement is taken during inspiration.

[edit] Peak Expiratory Flow (PEF)

Normal values for Peak Expiratory Flow (PEF), shown on EU scale.[3]

Peak Expiratory Flow (PEF) is the maximal flow (or speed) achieved during the maximally
forced expiration initiated at full inspiration, measured in litres per minute.

Tidal volume (TV)

Tidal volume (TV) is the specific volume of air drawn into, and then expired out of, the lungs
during normal tidal breathing.

[edit] Total Lung Capacity (TLC)

Total Lung Capacity (TLC) is the maximum volume of air present in the lungs.

[edit] Diffusion capacity (DLCO)

Diffusing Capacity (DLCO) is the carbon monoxide uptake from a single inspiration in a
standard time (usually 10 sec). This will pick up diffusion impairments, for instance in
pulmonary fibrosis. This must be corrected for anemia (because rapid CO diffusion is dependent
on hemoglobin in RBC's a low hemoglobin concentration, anemia, will reduce DLCO) and
pulmonary hemorrhage (excess RBC's in the interstitium or alveoli can absorb CO and
artificially increase the DLCO capacity).[dubious – discuss]

[edit] Maximum Voluntary Ventilation (MVV)

Maximum Voluntary Ventilation (MVV) is a measure of the maximum amount of air that can be
inhaled and exhaled in one minute, measured in liters/minute.
[edit] Technologies used in spirometers

Lilly type spirometry sensor.

 Volumetric Spirometers
o Water bell
o Bellows wedge
 Flow measuring Spirometers
o Fleisch-pneumotach
o Lilly (screen) pneumotach
o Turbine (actually a rotating vane which spins because of the air flow generated by the
subject. The revolutions of the vane are counted as they break a light beam)
o Pitot tube
o Hot-wire anemometer
o Ultrasound
Flow-Volume loop showing successful FVC maneuver. Positive values represent expiration, negative values
represent inspiration. The trace moves clockwise for expiration followed by inspiration. (Note the FEV 1 value is
arbitrary in this graph and just shown for illustrative purposes; these values must be calculated as part of the
procedure).
Spirometry requires that the nose is pinched off as the patient breathes through a
mouthpiece attached to the spirometer. The patient is instructed on how to breathe
during the procedure. Three breathing maneuvers are practiced before recording the
procedure, and the highest of three trials is used for evaluation of breathing. This
procedure measures air flow by electronic or mechanical displacement principles, and
uses a microprocessor and recorder to calculate and plot air flow.

The test produces a recording of the patient's ventilation under conditions involving
both normal and maximal effort. The recording, called a spirogram, shows the volume of
air moved and the rate at which it travels into and out of the lungs. Spirometry measures
several lung capacities. Accurate measurement is dependent upon the patient's
performing the appropriate maneuver properly. The most common measurements are:

 Vital capacity (VC). This is the amount of air (in liters) moved out of the lung during
normal breathing. The patient is instructed to breathe in and out normally to attain full
expiration. Vital capacity is usually about 80% of the total lung capacity. Because of the
elastic nature of the lungs and surrounding thorax, a small volume of air will remain in
the lungs after full exhalation. This volume is called the residual volume (RV).
 Forced vital capacity (FVC). After breathing out normally to full expiration, the patient is
instructed to breathe in with a maximal effort and then exhale as forcefully and rapidly
as possible. The FVC is the volume of air that is expelled into the spirometer following a
maximum inhalation effort.
 Forced expiratory volume (FEV). At the start of the FVC maneuver, the spirometer
measures the volume of air delivered through the mouthpiece at timed intervals of 0.5,
1.0, 2.0, and 3.0 seconds. The sum of these measurements normally constitutes about
97% of the FVC measurement. The most commonly used FEV measurement is FEV-1,
which is the volume of air exhaled into the mouthpiece in one second. The FEV-1 should
be at least 70% of the FVC.
 Forced expiratory flow 25–75% (FEF 25–75). This is a calculation of the average flow
rate over the center portion of the forced expiratory volume recording. It is determined
from the time in seconds at which 25% and 75% of the vital capacity is reached. The
volume of air exhaled in liters per second between these two times is the FEF 25–75.
This value reflects the status of the medium and small sized airways.
  Maximal voluntary ventilation (MVV). This maneuver involves the patient breathing as
deeply and as rapidly as possible for 15 seconds. The average air flow (liters per second)
indicates the strength and endurance of the respiratory muscles.

Normal values for FVC, FEV, FEF, and MVV are dependent on the patient's age, gender,
and height.

Purpose

Spirometry is the most commonly performed pulmonary function test (PFT). The test
can be performed at the bedside, in a physician's office, or in a pulmonary laboratory. It
is often the first test performed when a problem with lung function is suspected.
Spirometry may also be suggested by an abnormal x ray, arterial blood gas analysis, or
other diagnostic pulmonary test result. The National Lung Health Education Program
recommends that regular spirometry tests be performed on persons over 45 years old
who have a history of smoking. Spirometry tests are also recommended for persons with
a family history of lung disease, chronic respiratory ailments, and advanced age.

Spirometry measures ventilation, the movement of air into and out of the lungs. The
spirogram will identify two different types of abnormal ventilation patterns, obstructive
and restrictive.

Common causes of an obstructive pattern are cystic fibrosis, asthma, bronchiectasis,

bronchitis, and emphysema. These conditions may be collectively referred to by using
the acronym CABBE. Chronic bronchitis, emphysema, and asthma result in dyspnea
(difficulty breathing) and ventilation deficiency, a condition known as chronic
obstructive pulmonary disease (COPD). COPD is the fourth leading cause of death
among Americans.

Common causes of a restrictive pattern are pneumonia, heart disease, pregnancy, lung
fibrosis, pneumothorax (collapsed lung), and pleural effusion (compression caused by
chest fluid).
Obstructive and restrictive patterns can be identified on spirographs using both a "y"
and "x" axis. Volume (liters) is plotted on the y-axis versus time (seconds) on the x-axis.
A restrictive pattern is characterized by a normal shape showing reduced volumes for all
parameters. The reduction in volumes indicates the severity of the disease. An
obstructive pattern produces a spirogram with an abnormal shape. Inspiration volume
is reduced. The volume of air expelled is normal but the air flow rate is slower, causing
an elongated tail to the FVC.

A flow-volume loop spirogram is another way of displaying spirometry measurements.

This requires the FVC maneuver followed by a forced inspiratory volume (FIV). Flow
rate in liters per second is plotted on the y-axis and volume (liters) is plotted on the x-
axis. The expiration phase is shown on top and the inspiration phase on the bottom. The
flow-volume loop spirogram is helpful in diagnosing upper airway obstruction, and can
differentiate some types of restrictive patterns.

Some conditions produce specific signs on the spirogram. Irregular inspirations with
rapid frequency are caused by hyperventilation associated with stress. Diffuse fibrosis of
the lung causes rapid breathing of reduced volume, which produces a repetitive pattern
known as the penmanship sign. Serial reduction in the FVC peaks indicates air trapped
inside the lung. A notch and reduced volume in the early segments of the FVC is
consistent with airway collapse. A rise at the end of expiration is associated with airway
resistance.

Spirometry is used to assess lung function over time, and often to evaluate the efficacy of
bronchodilator inhalers such as albuterol. It is important for the patient to refrain from
using a bronchodilator prior to the evaluation. Spirometry is performed before and after
inhaling the bronchodilator. In general, a 12% or greater improvement in both FVC and
FEV-1, or an increase in FVC by 0.2 liters, is considered a significant improvement for
an adult patient.
Precautions

The patient should inform the physician of any medications he or she is taking, or of any
medical conditions that are present; these factors may affect the validity of the test. The
patient's smoking habits and history should be thoroughly documented. The patient
must be able to understand and respond to instructions for the breathing maneuvers.
Therefore, the test may not be appropriate for very young, unresponsive, or physically
impaired persons.

Spirometry is contraindicated in patients whose condition will be aggravated by forced

breathing, including:

 hemoptysis (spitting up blood from the lungs or bronchial tubes)

 pneumothorax (free air or gas in the pleural cavity)
 recent heart attack
 unstable angina
 aneurysm (cranial, thoracic, or abdominal)
 thrombotic condition (such as clotting within a blood vessel)
 recent thoracic or abdominal surgery
 nausea or vomiting

The test should be terminated if the patient shows signs of significant head, chest, or
abdominal pain while the procedure is in progress.

Spirometry is dependent upon the patient's full compliance with breathing instructions,
especially his or her willingness to extend a maximal effort at forced breathing.
Therefore, the patient's emotional state must be considered.

Preparation

The patient's age, gender, and race are recorded, and height and weight are measured
before the procedure begins. The patient should not have eaten heavily within three
hours of the test. He or she should be instructed to wear loose-fitting clothing over the
chest and abdominal area. The respiratory therapist or other testing personnel should
explain and demonstrate the breathing maneuvers to the patient. The patient should
practice breathing into the mouthpiece until he or she is able to duplicate the maneuvers
successfully on two consecutive attempts.

Aftercare

In most cases, special care is not required following spirometry. Occasionally, a patient
may become lightheaded or dizzy. Such patients should be asked to rest or lie down, and
should not be discharged until after the symptoms subside. In rare cases, the patient
may experience pneumothorax, intracranial hypertension, chest pain, or uncontrolled
coughing. In such cases, additional care directed by a physician may be required.

Normal results

The results of spirometry tests are compared to predicted values based on the patient's
age, gender, and height. For example, a young adult in good health is expected to have
the following FEV values:

 FEV-0.5—50-60% of FVC
 FEV-1—75-85% of FVC
 FEV-2—95% of FVC
 FEV-3—97% of FVC

In general, a normal result is 80–100% of the predicted value. Abnormal values are:

 mild lung dysfunction—60–79%

 moderate lung dysfunction—40–59%
 severe lung dysfunction—below 40%
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