Spirometry

Pulmonary function test

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

pulmonary function tests (PFTs). It measures lung function, specifically the
amount (volume) and/or speed (flow) of air that can be inhaled and exhaled.
Spirometry is helpful in assessing breathing patterns that identify conditions
such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD. It is also
helpful as part of a system of health surveillance, in which breathing patterns
are measured over time.

Quick Facts MeSH, OPS-301 code ...

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Doing spirometry

Spirometry generates pneumotachographs, which are charts that plot the

volume and flow of air coming in and out of the lungs from one inhalation
and one exhalation.

Testing

A modern USB PC-based spirometer.

Device for spirometry. The patient places his or her lips around the blue
mouthpiece. The teeth go between the nubs and the shield, and the lips go
over the shield. A nose clip guarantees that breath will flow only through the
mouth.

Screen for spirometry readouts at right. The chamber can also be used for
body plethysmography.
Spirometer

The spirometry test is performed using a device called a spirometer, which

comes in several different varieties. Most spirometers display the following
graphs, called spirograms:

A volume-time curve, showing volume (litres) along the Y-axis and time
(seconds) along the X-axis

A flow-volume loop, which graphically depicts the rate of airflow on the Y-axis
and the total volume inspired or expired on the X-axis

Procedure

The basic forced volume vital capacity (FVC) test varies slightly depending
on the equipment used. It can be in the form of either closed or open circuit.
Regardless of differences in testing procedure providers are recommended to
follow the ATS/ERS Standardisation of Spirometry. The standard procedure
ensures an accurate and objectively collected set of data, based on a
common reference, to reduce incompatibility of the results when shared
across differing medical groups.

The patient is asked to put on soft nose clips to prevent air escape and a
breathing sensor in their mouth forming an air tight seal. Guided by a
technician, the patient is given step by step instructions to take an abrupt
maximum effort inhale, followed by a maximum effort exhale lasting for a
target of at least 6 seconds. When assessing possible upper airway
obstruction, the technician will direct the patient to make an additional rapid
inhalation to complete the round. The timing of the second inhale can vary
between persons depending on the length of the proceeding exhale. In some
cases each round of test will be proceeded by a period of normal, gentle
breathing for additional data.

Limitations

Clinically useful results are highly dependent on patient cooperation and

effort and must be repeated for a minimum of three times to ensure
reproducibility with a general limit of ten attempts. Given variable rates of
effort, the results can only be underestimated given an effort output greater
than 100% is not possible.[citation needed]

Due to the need for patient cooperation and an ability to understand and
follow instructions, spirometry can typically only be done in cooperative
children when they at least 5 years old or adults without physical or mental
impairment preventing effective diagnostic results. In addition, General
anesthesia and various forms of sedation are not compatible with the testing
process.

Another limitation is that persons with intermittent or mild asthma can

present normal spirometry values between acute exacerbation, reducing
spirometry’s effectiveness as a diagnostic tool in these circumstances.
[citation needed]

Supplemental diagnostics

Spirometry can also be part of a bronchial challenge test, used to determine

bronchial hyperresponsiveness to either rigorous exercise, inhalation of
cold/dry air, or with a pharmaceutical agent such as methacholine or
histamine.

To assess the reversibility of a particular condition, a bronchodilator can be

administered before performing another round of tests for comparison. This
is commonly referred to as a reversibility test, or a post bronchodilator test
(Post BD), and is an important part in diagnosing asthma versus COPD.

Other complementary lung functions tests include plethysmography and

nitrogen washout.

Indications

Spirometry is indicated for the following reasons:

To diagnose or manage asthma

To detect respiratory disease in patients presenting with symptoms of

breathlessness, and to distinguish respiratory from cardiac disease as the
cause

To measure bronchial responsiveness in patients suspected of having asthma

To diagnose and differentiate between obstructive lung disease and

restrictive lung disease

To follow the natural history of disease in respiratory conditions

To assess of impairment from occupational asthma

To identify those at risk from pulmonary barotrauma while scuba diving

To conduct pre-operative risk assessment before anaesthesia or

cardiothoracic surgery

To measure response to treatment of conditions which spirometry detects

To diagnose the vocal cord dysfunction.

Contraindications

Forced expiratory maneuvers may aggravate some medical conditions.

Spirometry should not be performed when the individual presents with:

Hemoptysis of unknown origin

Pneumothorax

Unstable cardiovascular status (angina, recent myocardial infarction, etc.)

Thoracic, abdominal, or cerebral aneurysms

Cataracts or recent eye surgery

Recent thoracic or abdominal surgery

Nausea, vomiting, or acute illness

Recent or current viral infection

Undiagnosed hypertension

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), also known as
Maximum breathing capacity. 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. Multiple publications of predicted values have been
published and may be calculated based on age, sex, weight and ethnicity.
However, review by a doctor is necessary for accurate diagnosis of any
individual situation.

A bronchodilator is also given in certain circumstances and a pre/post graph

comparison is done to assess the effectiveness of the bronchodilator. See the
example printout.

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).

Average 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. Y-axis is
expressed in litres for FVC and FEV1, and in litres/second for FEF25–75%.

Output of a ‘spirometer’

Forced vital capacity (FVC)

Forced vital capacity (FVC) is the volume of air that can forcibly be blown out
after full inspiration, measured in liters. FVC is the most basic maneuver in
spirometry tests.

Forced expiratory volume in 1 second (FEV1)

FEV1 is the volume of air that can forcibly be blown out in first 1-second,
after full inspiration. Average values for FEV1 in healthy people depend
mainly on sex and age, according to the diagram. Values of between 80%
and 120% of the average value are considered normal. Predicted normal
values for FEV1 can be calculated and depend on age, sex, height, mass and
ethnicity as well as the research study that they are based on.

FEV1/FVC ratio

FEV1/FVC is the ratio of FEV1 to FVC. In healthy adults this should be

approximately 70–80% (declining with age). In obstructive diseases (asthma,
COPD, chronic bronchitis, emphysema) FEV1 is diminished because of
increased airway resistance to expiratory flow; the FVC may be decreased as
well, due to the premature closure of airway in expiration, just not in the
same proportion as FEV1 (for instance, both FEV1 and FVC are reduced, but
the former is more affected because of the increased airway resistance). This
generates a reduced value (<70%, 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.

A derived value of FEV1 is FEV1% predicted (FEV1%), which is defined as

FEV1 of the patient divided by the average FEV1 in the population for any
person of the same age, height, gender, and race.[medical citation needed]

Forced expiratory flow (FEF)

Forced expiratory flow (FEF) is the flow (or speed) of air coming out of the
lung during the middle portion of a forced expiration. It can be given at
discrete times, generally defined by what fraction of the forced vital capacity
(FVC) has been exhaled. The usual discrete intervals are 25%, 50% and 75%
(FEF25, FEF50 and FEF75), or 25% and 50% of FVC that has been exhaled. It
can also be given as a mean of the flow during an interval, also generally
delimited by when specific fractions remain of FVC, usually 25–75% (FEF25–
75%). Average ranges in the healthy population depend mainly on sex and
age, with FEF25–75% shown in diagram at left. Values ranging from 50 to
60% and up to 130% of the average are considered normal. Predicted normal
values for FEF can be calculated and depend on age, sex, height, mass and
ethnicity as well as the research study that they are based on.

MMEF or MEF stands for maximal (mid-)expiratory flow and is the peak of
expiratory flow as taken from the flow-volume curve and measured in liters
per second. It should theoretically be identical to peak expiratory flow (PEF),
which is, however, generally measured by a peak flow meter and given in
liters per minute.

Recent research suggests that FEF25-75% or FEF25-50% may be a more

sensitive parameter than FEV1 in the detection of obstructive small airway
disease. However, in the absence of concomitant changes in the standard
markers, discrepancies in mid-range expiratory flow may not be specific
enough to be useful, and current practice guidelines recommend continuing
to use FEV1, VC, and FEV1/VC as indicators of obstructive disease.

More rarely, forced expiratory flow may be given at intervals defined by how
much remains of total lung capacity. In such cases, it is usually designated as
e.g. FEF70%TLC, FEF60%TLC and FEF50%TLC.

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.[medical citation needed]

Peak expiratory flow (PEF)

Normal values for peak expiratory flow (PEF), shown on EU scale.

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

Tidal volume (TV)

Tidal volume is the amount of air inhaled or exhaled normally at rest.

[medical citation needed]

Total lung capacity (TLC)

Total lung capacity (TLC) is the maximum volume of air present in the lungs.
[medical citation needed]

Diffusing capacity (DLCO)

Diffusing capacity (or DLCO) is the carbon monoxide uptake from a single
inspiration in a standard time (usually 10 seconds). During the test the
person inhales a test gas mixture that consisting of regular air that includes
an inert tracer gas and CO, less than one percent. Since hemoglobin has a
greater affinity to CO than oxygen the breath-hold time can be only 10
seconds, which is a sufficient amount of time for this transfer of CO to occur.
Since the inhaled amount of CO is known, the exhaled CO is subtracted to
determine the amount transferred during the breath-hold time. The tracer
gas is analyzed simultaneously with CO to determine the distribution of the
test gas mixture. This test will pick up diffusion impairments, for instance in
pulmonary fibrosis. This must be corrected for anemia (a low hemoglobin
concentration will reduce DLCO) and pulmonary hemorrhage (excess RBC’s
in the interstitium or alveoli can absorb CO and artificially increase the DLCO
capacity). Atmospheric pressure and/or altitude will also affect measured
DLCO, and so a correction factor is needed to adjust for standard pressure.

Maximum voluntary ventilation (MVV)

Maximum voluntary ventilation (MVV) is a measure of the maximum amount

of air that can be inhaled and exhaled within one minute. For the comfort of
the patient this is done over a 15-second time period before being
extrapolated to a value for one minute expressed as liters/minute. Average
values for males and females are 140–180 and 80–120 liters per minute
respectively.[medical citation needed]

Static lung compliance (Cst)

When estimating static lung compliance, volume measurements by the

spirometer needs to be complemented by pressure transducers in order to
simultaneously measure the transpulmonary pressure. When having drawn a
curve with the relations between changes in volume to changes in
transpulmonary pressure, Cst is the slope of the curve during any given
volume, or, mathematically, ΔV/ΔP. Static lung compliance is perhaps the
most sensitive parameter for the detection of abnormal pulmonary
mechanics. It is considered normal if it is 60% to 140% of the average value
in the population for any person of similar age, sex and body composition.

In those with acute respiratory failure on mechanical ventilation, “the static

compliance of the total respiratory system is conventionally obtained by
dividing the tidal volume by the difference between the ‘plateau’ pressure
measured at the airway opening (PaO) during an occlusion at end-inspiration
and positive end-expiratory pressure (PEEP) set by the ventilator”.

Measurement Approximate value

Male Female

Forced vital capacity (FVC) 4.8 L 3.7 L

Tidal volume (Vt) 500 mL 390 mL

Total lung capacity (TLC) 6.0 L 4.7 L

Others

Forced Expiratory Time (FET)

Forced Expiratory Time (FET) measures the length of the expiration in

seconds.
Slow vital capacity (SVC)

Slow vital capacity (SVC) is the maximum volume of air that can be exhaled
slowly after slow maximum inhalation.

Maximal pressure (Pmax and Pi)

Spirometer – ERV in cc (cm3) average Age 20

Male Female

4320 3387

Pmax is the asymptotically maximal pressure that can be developed by the

respiratory muscles at any lung volume and Pi is the maximum inspiratory
pressure that can be developed at specific lung volumes. This measurement
also requires pressure transducers in addition. It is considered normal if it is
60% to 140% of the average value in the population for any person of similar
age, sex and body composition. A derived parameter is the coefficient of
retraction (CR) which is Pmax/TLC .

Mean transit time (MTT)

Mean transit time is the area under the flow-volume curve divided by the
forced vital capacity.

Maximal inspiratory pressure (MIP) MIP, also known as negative inspiratory

force (NIF), is the maximum pressure that can be generated against an
occluded airway beginning at functional residual capacity (FRC). It is a
marker of respiratory muscle function and strength. Represented by
centimeters of water pressure (cmH2O) and measured with a manometer.
Maximum inspiratory pressure is an important and noninvasive index of
diaphragm strength and an independent tool for diagnosing many illnesses.
Typical maximum inspiratory pressures in adult males can be estimated from
the equation, MIP = 142 – (1.03 x Age) cmH2O, where age is in years.
Technologies used in spirometers

Volumetric Spirometers

Water bell

Bellows wedge

Flow measuring Spirometers

Fleisch-pneumotach

Lilly (screen) pneumotach

Turbine/Stator Rotor (normally incorrectly referred to as a 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)

Pitot tube

Hot-wire anemometer

Ultrasound