Brief Summation of Pulmonary Function

Tests
Useful Websites / References

Pulmonary Function Testing

Spirometry
Obstructive conditions

Static lung volumes

Diffusing capacities
Restrictive conditions
Intrapulmonary
Extrapulmonary

Other tests
Z scores
Tips

Spirometry
Forced expiratory volume in 1 second (FEV1)
Volume exhaled in the first second of an FVC
manoeuvre (forced exhalation from maximal
inspiration)

Vital capacity (VC)

Total volume exhaled by a exhalation from
maximal inspiration
Can be a forced exhalation (FVC) or a relaxed
exhalation (RVC) best one taken as VC

FEV1/VC
Ratio between FEV1 and VC

Spirometry

Obstructive Airways Disease

FEV 1 , VC /, FEV1/VC < 0.7
Common causes
COPD
Emphysema
Chronic bronchitis

Asthma

(can be normal if well)

Less common causes

Large airway obstruction
(ratio may not be <
0.7)
Bronchiectasis
(ratio may not be < 0.7)
Obliterative broncholitis
(post lung transplant)

Restrictive Lung Disease

FEV 1 , VC / , ratio /
Can be split into intrapulmonary
restrictive and extrapulmonary
restrictive causes

Static Lung Volumes

Total lung capacity (TLC)
Total volume of air in the lungs at the
end of an maximal inspiration

Residual volume (RV)

Volume of air remaining in the lungs at
the end of a maximal expiration

Functional residual volume (FRC)

Volume of air remaining in the lungs at
the end of tidal expiration

Technique
Whole body plethysmography / body
box
Calculates FRC other static lung
volumes calculated from this

Causes of Abnormal Lung

Volumes
Reduced TLC
Restrictive defect (intrapulmonary or
extrapulmonary)

Raised TLC
COPD esp. emphysema
Transiently during/recovering from asthma
exacerbation

Increased RV
Airways disease
(air-trapping)
Respiratory muscle weakness
(extrapulmonary)

Causes of Abnormal Lung

Volumes
Raised FRC
COPD incl. emphysema

Reduced FRC
Fibrotic lung disease (intrapulmonary)
Obesity
(extrapulmonary)

Diffusion Capacity
TLCO = transfer factor for the lung for
carbon monoxide i.e. Total diffusing
capacity for the lung
Same as DLCO

KCO = transfer coefficent i.e. Diffusing

capacity of the lung per unit volume,
standardised for alveolar volume (VA)
VA = Lung volume in which carbon
monoxide diffuses into during a single
breath-hold technique

Diffusion Capacity
Technique
Single breath hold methane/helium
technique

TLCO = KCO x VA
Corrected for Hb

Abnormal Diffusion Capacity

Low TLC: Low TLCO and low/normal
KCO = intrapulmonary restrictive defect
Interstitial lung diseases e.g. Idiopathic
pulmonary fibrosis, sarcoidosis, CTD, HP
Cardiac e.g. Pulmonary oedema
Pulmonary vascular disease e.g. Pulmonary
hypertension (may have normal TLCO)

High TLC: Low TLCO + KCO

emphysema (in the context of obstruction)

Abnormal Diffusion Capacity

Low TLCO but high KCO = extrapulmonary
restrictive defect
Obesity
Respiratory muscle weakness (neuromusclar)
Pleural disease e.g. effusion, encasement
Skeletal e.g. Ankolysing spond., thoracoplasty,
severe kyphoscoliosis
Severe dermatological disease e.g.
Scleroderma

Also: post pneumonectomy

Abnormal Diffusion Capacity

Normal/raised TLCO + raised KCO
Asthma
Pulmonary haemorrhage e.g. vasculitis

Other tests
Reversibility testing
Spirometry before and after bronchodilator e.g.
Salbutamol
> 12% or 200ml change in either FEV1 or VC
provides some evidence of reversibility =
possibility of asthma
>20% or 400ml change in either FEV1 or VC
provides strong evidence of reversibility =
strong possibility of asthma
Absence of reversibility does not rule out
asthma

Other tests
Erect/supine spirometry
Screening for respiratory muscle weakness

Flow/volume loop
Localising large airway obstruction
Respiratory muscle weakness

Mouth pressures
Inspiratory muscle weakness vs. expiratory

Cardiopulmonary exercise testing

Z scores

Z scores
95 % of the population should be
within a Z score between +1.64 to
-1.64
Therefore any value < -1.64 or >
+1.64 is abnormal
Although it depends on what Z score
they started off with trends are more
important than absolute values if
available

Tips
Go through the PFTs systematically
Spirometry -> lung volumes -> diffusing
capacities

Try and classify the abnormality

Obstructive
Extrapulmonary restrictive defect
Intrapulmonary restrictive defect
Mixed picture

Only make a diagnosis if the rest of the

clinical picture given is in keeping with the
PFTs

Tips
Even if the Z scores do not completely
reach significance, if there is a definable
pattern then consider PFTs tending
towards
Dont be afraid to call it normal if it is!
Dont get confused about spirometry ratio
0.7 is obstructive
There isnt a restrictive ratio, if FEV1 and VC
are significantly down then spiromety suggests
restriction. If they are not significantly down,
then a ratio of > 0.7 is normal.

Tips
TLC + VA measure the same thing in different
ways
TLC measures lung volume incl. non-ventilated
areas, VA only measures ventilated areas and
therefore TLC should be > VA
Technical issues if TLC < VA
If TLC >> VA volume gap emphysema in
context of obstruction

Dont call it extrapulmonary unless KCO is

supranormal (>100% predicted) in restriction

FEV1 VC
Asthma
(can be
normal)

COPD
(Emphysema)

Rati TLC TLCO

o

KCO

Intrapulmonary
Restrictive
Disease

Extrapulmonar
y
Restrictive
Disease

http://emedicine.medscape.com/article/303239overview#aw2aab6b4

http://www.brit-thoracic.org.uk/guidelines/lung-cancerguidelines.aspx
http://www.nice.org.uk/nicemedia/live/13029/49399/49399.pdf

Description
Already established as a 'classic' in the field,
Clinical Tests of Respiratory Function
presents an authoritative yet accessible
account of this complex area, fusing the
basic principles of respiratory physiology
with applications in clinical practice across a
wide range of disorders.
This third edition has been extensively
revised to reflect advances in our
understanding of respiratory function at rest,
on exercise and during sleep, together with
technological developments related to
investigation and treatment. Now subdivided
into four practical sections, users can easily
pick their desired topic, from the commonly
used tests and their underlying physiological
mechanisms to abnormalities of function in
both respiratory and non-respiratory
diseases. The book concludes with a helpful
section on test interpretation, new to this
edition.
This eagerly awaited revision will quickly
find a place on the bookshelves of all
practitioners clinicians and laboratory
investigators who have an interest in
respiratory function.

"...a dominating and outstanding reference

for students and practitioners in the field of
pulmonology and respiratory care."--Doody's

About the Author

G.J Gibson, Emeritus Professor of Respiratory
Medicine, University of Newcastle upon
Tyne; and Consultant Respiratory Physician,
Freeman Hospital, Newcastle upon Tyne, UK