P U L M O N A R

PULMONARY
Y
FUNCTION
F U N C T I O N
TT EE SS TT SS
DR ELIAS TEKLESELASSIE
 OUTLINE
• Spirometry and lung volumes

• Flow volume loops and maximal pressures

• Broncho provocative and exercise testing

• Pulse oximetry

• DLCO

• Putting it together

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 Measures of flow and volume Others

• Spirometry • DLCO

– Bronchodilator responsiveness • Maximal inspiratory and

– Bronchoprovocation expiratory pressures
• Flow-volume loops • ABG and Pulseoximetry

• Body plethysmography • Exercise testing

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S P I R O M E T RY
• Physiological test that measures the maximal volume of air
that an individual can inspire and expire with maximal effort

• Useful in evaluating respiratory symptoms, monitoring lung

disease, assessing effect of drugs and evaluating people at
risk of lung disease

• Can be office or lab based

 Indications
 Evaluation of symptoms, physiologic effect of disease, screening

individuals at risk of pulmonary disease and preoperative assessment

 Monitoring of disease progression, treatment response and effect of

injurious toxins or drugs

 Disability assessment

 Others including research and clinical trials, derivation of reference

equations, occupational monitoring and assessment

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 Contraindications
 Recent MI, severe hypo/hypertension, significant arrhythmias, non-

compensated heart failure, uncontrolled pulmonary hypertension, unstable

pulmonary embolism, history of syncope related to forced expiration/cough
 Increases in intracranial/intraocular pressure

 Sinus surgery or middle ear surgery or infection within 1 week

 Increases in intrathoracic and intra-abdominal pressure

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 Preparations
 Ambient temperature, barometric pressure, and time of day must be

recorded.
 Patient should be properly seated

 For patients suspected of having, tuberculosis, hemoptysis, oral lesions,

or other known transmissible infectious diseases.

– Use of dedicated equipment for infected patients or
– Testing these patients at the end of the day to allow disinfection and use
of separate rooms with ventilation

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 Activities That Should Be Avoided before Lung Function Testing

Smoking and/or vaping and/or water pipe use within 1 h before testing

Consuming intoxicants within 8 h before testing

Performing vigorous exercise within 1 h before testing

Wearing clothing that substantially restricts full chest and abdominal

expansion

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 Withholding
Bronchodilator
Time
Medication SABA (e.g., albuterol or salbutamol) 4–6 h

SAMA (e.g., ipratropium bromide) 12 h

LABA (e.g., formoterol or salmeterol) 24 h

Ultra-LABA (e.g., indacaterol, vilanterol, or olodaterol) 36 h

LAMA (e.g., tiotropium, umeclidinium, aclidinium, or 36–48 h
glycopyrronium)

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 PROCEDURE
• Take as deep a breath as possible

• Blast out the air into the spirometer without

hesitation after reaching a full inspiration

• Continue exhaling until a plateau in exhaled volume

or 15 seconds is reached, unless just measuring
FEV6 (exhalation until six seconds)

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 • Inspiration needs to be rapid and pause at full inspiration should be minimal (≤2 s),
if not can falsely reduce PEF and FEV1

• Maximal inspiration is normally uncomfortable and sometimes the patient's head

will begins to quiver if patient looks comfortable is unlikely to be at full inflation

• Procedure needs to be repeated for a minimum of 3 manoeuvres but not more than
8 times.

• FEV1 drop of below 80% of initial value indicates the patient is getting tired and
testing should be stopped for patient safety

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 Supine and sitting spirometry
• Diaphragmatic weakness – decrease in supine vital capacity (VC) >10 percent.
• Unilateral diaphragmatic paralysis – decrease in VC of 15 - 25 percent
• Bilateral diaphragmatic paralysis – decrease in supine VC approaching 50 percent

Slow vital capacity (SVC)

• Useful when the FVC is reduced and airway obstruction is present as slow
exhalation results in a lesser degree of airway narrowing and a higher, even
normal vital capacity.

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 QUALITY
3 important factors to insure quality
– Accurate and precise instruments
– A patient capable of performing required maneuvers
– Motivated technologist to illicit maximal patient performance

• Most of the variability in spirometry – Inadequate inspiration to TLC,

ending expiration prematurely, and variable effort.

• Daily calibration of spirometer with 3L calibration syringe is recommended

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 Acceptability Criteria Required Required
for FEV1 For FVC
BEV <5% of FVC or 0.100 L, whichever is greater Yes Yes
No evidence of a faulty zero-flow setting Yes Yes
No cough in the first second of expiration Yes No
No glottic closure in the first second of expiration Yes Yes
No glottic closure after 1 second of expiration No Yes
One of the three end of expiration indicators No Yes
No evidence of obstructed mouthpiece or spirometer Yes Yes
No evidence of leak Yes Yes
If the maximal inspiration after EOFE is greater than FVC, then FIVC 2 Yes Yes
FVC must be <0.100 L or 5% of FVC, whichever is greater

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 B R O N C H O D I L AT O R R E S P O N S E

 Bronchodilator responsiveness is continuous

rather than dichotomous

 Threshold for response of 10% of predicted

change in FEV or FVC is recommended cut-off

rather than the traditional 12% + 200 ml
 Bronchodilator response in FVC, rather than

FEV1 better reflects the physiological

processes of air trapping

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RESULTS
Having BDR defined from absolute change was biased toward men (male to female
ratio, 2.70) and toward those with larger baseline FEV 1. BDR defined by % change
from baseline was biased toward those with lower baseline values. BDR defined by %
predicted had no sex or size bias. Multivariate Cox regression found those with
FEV1 BDR > 8% predicted (33% of the subjects) had an optimal survival advantage
(hazard ratio, 0.56; 95% CI, 0.45-0.69) compared with those with FEV 1 BDR ≤ 8%
predicted. The survival of those with FEV1 BDR > 8% predicted was not significantly
different from that of those with FEV1 BDR > 14% predicted but was significantly
better than that of those with FEV1 BDR < 0.
 Severity of obstruction/restriction
compared to predicted Z-score(for all measures)

Mild: FEV1 >70% predicted Mild: −1.65 to −2.5

Moderate: 60–69% predicted Moderate: −2.51 to −4.0

Moderate-to-severe: 50–59% predicted Severe: <−4.1

Severe: 35–49% predicted

Very severe: <35% predicted

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 LU N G V O LU M E S
Capacities – combinations of ≥ 2
volumes
• Static: TV, IRV, ERV

• Dynamic: FEV1, FVC, FEV6, FEF

25 - 75%

• Lung Capacities: IC, VC, TLC

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Term Definition
Residual volume (RV) Volume of air remaining in the lungs after maximal expiration

Expiratory reserve volume Maximal volume of air expired from the resting end-expiratory level
(ERV)
Tidal volume (TV) Volume of air inspired or expired with each breath during quiet breathing

Inspiratory reserve volume Maximal volume of air inspired from the resting end-inspiratory level
(IRV)
Inspiratory capacity (IC) Maximal volume of air inspired from the end-expiratory level (the sum of
IRV and TV)
Vital capacity (VC) Maximal volume of air expired form the maximal inspiratory level

Inspiratory vital capacity IVC) Maximal volume of air inspired form the maximal expiratory level

Functional residual capacity Volume of air remaining in the lungs at the end-expiratory level (the sum
(FRC) of RV and ERV)
Total lung capacity (TLC) Volume of air in the lungs after maximal inspiration (the sum of all volume
compartments)
Other tests
 Helium dilution

 Nitrogen washout

 Body plethysmography

– Is a faster method compared to the others

– Static lung volumes can be obtained by
measuring changes in pressure in a constant
volume box or volume in a constant pressure box
 F LO W-VO LU M E LO O P S
• Aid in the diagnosis and localization of airway
obstruction

• Useful to asses stridor and unexplained dyspnea

• Characteristic loop patterns are also often found in

certain disease but are not considered primary
diagnostic aids

• Luminal obstruction needs to be significant before

abnormalities are detected in upper airway
obstruction

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Abnormalities in expiratory loop
• Variable intrathoracic obstruction - tracheomalacia of
the intrathoracic airway, bronchogenic cysts, or with
tracheal lesions (often malignant)

• Main-stem bronchus obstruction – if complete can

result in restrictive and if partial mixed obstructive
and restrictive pattern

• Lower airway obstruction - Asthma, COPD,

bronchiectasis, and bronchiolitis
Abnormalities in inspiratory loop
Variable extra-thoracic obstruction

• Caused by vocal fold paralysis, laryngomalacia, extra-

thoracic tracheomalacia, polychondritis, mobile
tumors

• Turbulent flow and a Venturi effect also worsen

narrowing and flow limitation

• FEF50/FIF50 is elevated, with an average value of 2.2

Abnormalities in inspiratory and expiratory loops
• Fixed upper airway obstruction - Firm tracheal lesions
can limit the modulating effect of transmural pressures

• Extra-luminal tracheal obstruction

• Saw-tooth pattern - neuromuscular diseases, Parkinson

disease, laryngeal dyskinesia, pedunculated tumors of
the upper airway, tracheobronchomalacia, upper airway
burns and obstructive sleep apnea
 M A X I M A L R E S P I RAT O RY P R E S S U R E S
 Assessment of respiratory muscle strength

 Only equipment required to measure pressures is an aneroid

vacuum and pressure gauge

 Particularly important for assessment of respiratory muscle

weakness in patients with neuromuscular disease

Pi max Pe max
Predicted(cm H₂O) LLN Predicted(cm H₂O) LLN

Male 143 − (0.55 x age) 71 268 − (1.03 × age) 111

Female 104 – (0.55 x age) 39 70 − (0.53 × age) 88

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 B R O N C H I A L P R O V O C AT I O N T E S T I N G

Asthma diagnosis requires demonstration of airway

hyper-responsiveness

Degree of hyper-responsiveness correlates with

severity of airway obstruction, has prognostic and
treatment implications

Requires precautions and spirometry needs to be

adequate

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 Indications
Diagnosis
Lack of bronchodilator response, atypical symptoms, occupational
asthma and individuals who require screening

Treatment response (novel therapies)

Identification of triggers

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 Contraindications
Airflow limitation
FEV1 < 60% (50%) or <1.5L
FEV1 < 75% for exercise or eucapnic voluntary hyperventilation

Inability to perform adequate spirometry and testing maneuvers

Cardiovascular
Recent MI, uncontrolled hypertension, aortic aneurysm, recent eye
surgery or increased intracranial hypertension

Recent URTI and influenza vaccination

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Medication Time
SABA 8 hours

LABA 36 hours

SAMA 12 hours

ICS 6 – 24 hours

OCS 2-3 weeks

Antihistamines 72 hours

Montelukast 4 days
 Pharmacologic
Direct – Methacholine, histamine
Indirect – Mannitol, adenosine monophosphate

Exercise – on a treadmill or bicycle

Eucapnic voluntary hyperpnea (dry air with 4.5-5%

CO₂)

Antigen testing (Toluene diisocyanate, Bacillus

subtilis, Pollen, Molds, House dust and food additives)

Aspirin challenge

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 E X E RC I S E T E S T I N G
The 6 minute walk test
 Index of physical function and therapeutic response

 Improves with

- pulmonary rehabilitation in COPD,

- Pharmacologic interventions for pulmonary arterial

hypertension and heart failure
- Lung transplantation and lung volume reduction surgery
for emphysema

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 Incremental shuttle walk test
12 step test with progressively increasing speed over 10 meter trips over 12
minutes

Correlates with maximum oxygen uptake (VO₂ max)

Primary measure is distance covered

Endurance shuttle walk test

Constant speed with cones 10 meter apart, test is continued until the patient gets
tired or until 20 minutes lapse

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 P U L S E OX I M E T RY

Uses spectrophotometry, emits light at two wavelengths to

detect oxygenated and deoxygenated hemoglobin

Gives rapid, non-invasive and continuous measurements

But cant detect hyperoxemia, can miss hypoxemia and cant

assess hypoventilation(PaCO2)

Claimed accuracy by manufacturers is 2-3% for SPO2 70-100%

but in practice less reliable when below 90% (especially < 80%)

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 Ear and forehead probes respond more quickly to change
than fingers
– 94 vs 100 sec for desaturation and 23 vs 29 seconds for
increase in saturation
– May also be used in patients with low perfusion

 Falsely low – Hemoglobin abnormalities, severe

anemia(Hg<5mg/dl), venous congestion, nail polish, artificial

nails
 Falsely high – Carboxyhemoglobin (CO poisoning, smokers),

Increased HgA1C and patients with darker pigmentation

DLCO
• Measure of gas transfer from inspired air to RBCs
via pulmonary capillaries

• Correlated with membrane conductance, reaction

rate and pulmonary capillary blood volume
• .

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Indications
 Evaluation of dyspnea or hypoxemia

 Evaluation of emphysema

 Evaluation for presence and monitoring of interstitial lung disease

 Prior to lung volume restriction surgery

 Detection of pulmonary vascular disease

 Pulmonary disability/impairment evaluation

Single breath technique
 Tidal breathing for a few breaths followed by unforced

expiration to RV
 Single full, rapid inspiration of a gas mixture

 The breath is held for 10 ± 2 s and then rapidly

expired.
 An inspiratory time of less than 4 s, and a sample

collection of no more than 3 s, are required

Z score Diffusion abnormality DLCO
Z-score >1.645 Abnormally high DLCO > 140%
Z-score –1.645 to DLCO 76 to 140%
Normal
1.645 predicted
DLCO 61 to 75%
Z-score –1.65 to –2.5 Mild impairment
predicted
DLCO 41 to 60%
Z-score –2.5 to –4.0 Moderate impairment
predicted
Z-score <–4.0 Severe impairment DLCO <40% predicted
Increased DLCO Low DLCO with obstruction with or
Altitude without concomitant restriction

Asthma Bronchiolitis

Polycythemia Combined pulmonary fibrosis and emphysema

Severe obesity Cystic fibrosis

Pulmonary hemorrhage Emphysema
Left-to-right intracardiac shunting Interstitial lung disease in patient with COPD
Mild left heart failure
Lymphangioleiomyomatosis
Exercise just prior to testing
Sarcoid
Mueller maneuver
Supine position Low DLCO with normal spirometry and
lung volume
Anemia - mild decrease
Low DLCO with restriction Pulmonary vascular disease - mild to severe
decrease
Interstitial lung disease Early interstitial lung disease - mild to
moderate decrease
Pneumonitis
Valsalva maneuver
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CLINICAL VIGNETTES
A 56 years old smoker
presents with a progressive,
productive cough and dyspnea
of 3 months of duration
 REFERENCES
• Fishmans_Pulmonary_Diseases_and_Disorders,_6th Ed, 2023

• Murray_&_Nadel’s_Textbook_of_Respiratory_Medicine_7th_Ed, 2022

• Up-to-date

• ERS/ATS 2022 technical standard on interpretive strategies for routine lung function tests

• ATS standardization of spirometry 2019 Update

• du Bois et al Six-minute-walk test in idiopathic pulmonary fibrosis: test validation and minimal clinically
important difference. Am J Respir Crit Care Med. 2011 May 1;183(9):1231-7. doi: 10.1164/rccm.201007-
1179OC.

• Fawzy A et al Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment
Eligibility Among Patients With COVID-19. JAMA Intern Med. 2022 Jul 1;182(7):730-738. doi:
10.1001/jamainternmed.2022.1906

• Amsalu Binegdie et al Chronic respiratory disease in adult outpatients in three African countries: a cross-
sectional study INT J TUBERC LUNG DIS 26(1):18–25 Q 2022 The Union http://dx.doi.org/10.5588/ijtld.21.0362.

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T H A N K YO U