Lung function
Tests
Dr. PARTHA PRATIM DEKA
Pulmonary function tests
(PFTs)
• Pulmonary function testing is a valuable
tool for evaluating the respiratory system
• comparing the measured values for
pulmonary function tests obtained on a
patient at any particular point with normal
values derived from population studies.
• The percentage of predicted normal is
used to grade the severity of the
abnormality.
Pulmonary Function
Tests
• Evaluates 1 or more major
aspects of the respiratory
system
PFTs
• Four lung components include :
The airways (large and small),
Lung parenchyma (alveoli,
interstitium),
Pulmonary vasculature, and
The bellows-pump mechanism
PFTs
• PFTs can include:
simple screening spirometry, Flow Volume Loop
Formal lung volume measurement,
Bronchoprovocation testing
Diffusing capacity for carbon monoxide, and
Arterial blood gases. Measurement of
maximal respiratory pressures
• These studies may collectively be referred to as a
complete pulmonary function survey.
Spirometry
• Measurement of the pattern of air
movement into and out of the lungs
during controlled ventilatory
maneuvers.
• Often done as a maximal expiratory
maneuver
Importance
• Patients and physicians have inaccurate
perceptions of severity of airflow
obstruction and/or severity of lung disease
by physical exam
• Provides objective evidence in identifying
patterns of disease
Spirometry
Simple, office-based
Measures flow, volumes
Volume vs. Time
Can determine:
- Forced expiratory volume in one second (FEV1)
- Forced vital capacity (FVC)
- FEV1/FVC
- Forced expiratory flow 25%-75% (FEF25-75)
Spirometry
The most readily available most useful
pulmonary function test
It takes ten to 15 minutes
carries no risk
Spirometry
• Spirometry is the most commonly used lung
function screening study.
• should be the clinician's first option
• other studies being reserved for specific indications
• easily performed
• in the ambulatory setting, physician's office, emergency
department, or inpatient setting.
Patient care/preparations
• Two choices are available with respect to bronchodilator
and medication use prior to testing. Patients may withhold
oral and inhaled bronchodilators to establish baseline lung
function and evaluate maximum bronchodilator response,
or they may continue taking medication as prescribed. If
medications are withheld, a risk of exacerbation of bronchial
spasm exists.
Spirometry
• The slow vital capacity (SVC) can also be measured
with spirometers
collect data for at least 30 seconds
when airways obstruction is present, the forced vital
capacity (FVC) is reduced and
slow vital capacity (SVC) may be normal
Spirometry
• When the slow or forced vital capacity is within the normal
range: No significant
restrictive
disorder .
No need to measure static lung volumes (residual volume and
total lung capacity).
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
Indications — Diagnosis
Evaluation of signs and symptoms
- SOB, exertional dyspnea, chronic cough
Screening at-risk population
s
Smokers > 45yo
Monitoring pulmonary (former
toxicity & current)
drug
Abnormal study
- CXR, EKG, ABG, hemoglobin
Preoperative assessment
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
Indications — Prognostic
■ Assess severity
■ Follow response to therapy
■ Determine further treatment goals
■ Referral for surgery
■ Disability
Contraindications for
spirometry
• Relative contraindications for spirometry include hemoptysis
of unknown origin, pneumothorax, unstable angina pectoris,
recent myocardial infarction, thoracic aneurysms, abdominal
aneurysms, cerebral aneurysms, recent eye surgery
(increased intraocular pressure during forced expiration),
recent abdominal or thoracic surgical procedures, and
patients with a history of syncope associated with forced
exhalation
Spirometry
• Spirometry requires a voluntary maneuver in which a seated
patient inhales maximally from tidal respiration to total lung
capacity and then rapidly exhales to the fullest extent until
no further volume is exhaled at residual volume
Spirometry
• The maneuver may be performed in a forceful manner to
generate a forced vital capacity (FVC) or in a more
relaxed manner to generate a slow vital capacity (SVC).
• In normal persons, the inspiratory vital capacity, the
expiratory SVC, and expiratory FVC are essentially equal.
However, in patients with obstructive airways disease, the
expiratory SVC is generally higher than the FVC.
Interpretation of spirometr y
results(1)
• should begin with an
assessment of test quality.
to inspect the graphic data
(the volume-time curve and
the flow-volume loop)
Interpretation of
spirometry results(2)
• to ascertain whether the study
meets certain well-defined
acceptability and
reproducibility standards
acceptable spirometry
(ATS)
• 1) minimal hesitation at the start of the forced
expiration (extrapolated volume (EV) <5% of the FVC or
0.15 L, whichever is larger
• Time to PEF is <120 ms (optional until further information
is available)
(2) no cough in the first second of forced exhalation,
• 3) meets 1 of 3 criteria that define a valid end-of-test
Valid end-of-test
• (a) smooth curvilinear rise of the volume-time tracing to
a plateau of at least 1-second duration;
(b) if a test fails to exhibit an
expiratory plateau, a forced expiratory time (FET) of 15
seconds; or
(c) when the patient
cannot or should not continue forced exhalation for
valid medical reasons.
• If both of these criteria are not met, continue testing
until: Both of the criteria are met with analysis of
additional acceptable spirograms or
• A total of eight tests have been performed or
• Save a minimum of three best maneuvers
Acceptability Criteria
• Good start of test
• No coughing
• No variable flow
• No early termination
• Reproducibility
The volume-time tracing
• The volume-time tracing is most useful in assessing
whether the end-of-test criteria have been met
Spirometry
Flow-volume loop
• the flow-volume loop is
most valuable in
evaluating the start-of-
test criteria.
Flow-Volume Loop
•
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed.,
Mosby 2003
Repeatability Criteria
• After three acceptable spirograms have been obtained,
apply the following tests. Are the two largest FVCs within
0.2 L of each other?
• Are the two largest FEV1s within 0.2 L of each other?
•
Lung Volumes
Lung Volumes
• 4 Volumes
• 4 Capacities
IRV • Sum of 2 or more
IC lung volumes
TV ERV VC
TLC
FRC
RV RV
Spirometry
Lung Factors Affecting
Spirometry
• Mechanical properties
• Resistive elements
Mechanical Properties
• Compliance
• Describes the stiffness of the lungs
• Change in volume over the change in pressure
• Elastic recoil
• The tendency of the lung to return to it’s resting state
• A lung that is fully stretched has more elastic recoil and thus
larger maximal flows
Resistive Properties
• Determined by airway caliber
• Affected by
• Lung volume
• Bronchial smooth muscles
• Airway collapsibility
Factors That Affect Lung Volumes
• Age
• Sex
• Height
• Weight
• Race
• Disease
Technique
• Have patient seated comfortably
• Closed-circuit technique
• Place nose clip on
• Have patient breathe on mouthpiece
• Have patient take a deep breath as fast as possible
• Blow out as hard as they can until you tell them to stop
Terminology ):
be
• Forced vital capacity (FVC
• Total volume of air that
can 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
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
• 60%-75% Mild obstruction
• 50-59% Moderate obstruction
• <49% Severe obstruction
FE F
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
• <10% Severe obstruction
Flow-Volume Loop
• Illustrates maximum
expiratory and
inspiratory flow- e
volum curves
• Useful to help
characterize disease
states (e.g.
obstructive vs.
restrictive)
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed.,
Mosby 2003
Categories of Disease
• Obstructive
• Restrictive
• Mixed
Obstructive Disorders
• Characterized by a
limitation of
expiratory airflow
• Examples: asthma, COPD
• Decreased: FEV1, FEF25-
75, FEV1/FVC ratio
(<0.8)
• Increased or
Normal: TLC
Spirometry in Obstructive
Disease
• Slow rise in upstroke
• May not reach plateau
Restrictive Lung Disease
• Characterized by diminished lung
volume due to:
• change in alteration in lung
parenchyma (interstitial lung
disease)
• disease of pleura, chest wall
(e.g. scoliosis), or neuromuscular
apparatus (e.g. muscular dystrophy)
• Decreased TLC, FVC
• Normal or increased: FEV1/FVC ratio
Restrictive Disease
• Rapid upstroke as n
i normal
spirometry
• Plateau volume
is low
Large Airway Obstruction
• Characterized by a
truncated
inspiratory or
expiratory loop
Normal Spirometry
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 restrictivecomponent
- Differentiate chronic bronchitis from
emphysema
Pulmonary Function Testing
The Basics of Interpretation
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
Expensive!
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
Continued…
SYMPTOMS
↓
PFTs
↓
OBSTRUCTION?
↓ ↓
YES NO
↓ ↓
BRONCHOPROVOCATION
TREAT
↓ ↓
No Obstruction?
Obstruction? Other Diagnosis
TREAT
PFT Interpretation Strategy
What is the clinical question?
What is “normal”?
Did the test meet American Thoracic Society (ATS) criteria?
Don’t forget (or ignore) the flow volume loop!
Obstructive Pattern — Evaluation
Spirometry
FEV1, FVC: decreased
FEV1/FVC: decreased (<70% predicted)
FV Loop “scooped”
Lung Volumes
TLC, RV: increased
Bronchodilator responsiveness
Restrictive Pattern –
Evaluation
Spirometry
FVC, FEV1: decreased
FEV1/FVC: normal or increased
FV Loop “witch’s hat”
DLCO decreased
Lung Volumes
TLC, RV: decreased
Muscle pressures may be important
PFT Patterns
Emphysema Chronic
Bronchitis
FEV1/FVC
<70% DLCO decreased
“Scooped” FV curve
TLC increased
Increased
compliance
FEV1/FVC <70%
“Scooped” FV curve
TLC normal
Normal compliance
DLCO usually
normal
PFT Patterns
Asthma
FEV1/FVC normal or decreased
DLCO normal or increased
But PFTs may be normal bronchoprovocation
Thank you
