PULMONARY

FUNCTION TESTS

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 ANATOMY
 Lungs comprised of
 Airways
 Alveoli

http://www.aduk.org.uk/gfx/lungs.jpg 2
 THE AIRWAYS
 Conducting zone: no
gas exchange occurs
 Anatomic dead
space
 Transitional zone:
alveoli appear, but are
not great in number
 Respiratory zone:
contain the alveolar
sacs
Weibel ER: Morphometry of the Human
Lung. Berlin and New York: Springer-
Verlag, 1963 3
 MECHANICS OF BREATHING
 Inspiration
 Active process
 Expiration
 Quietbreathing: passive
 Can become active

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 PULMONARY FUNCTION TESTS
 Evaluates 1 or more major aspects of the
respiratory system
 Lung volumes
 Airway function
 Gas exchange

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 INDICATIONS — Diagnosis

 Evaluation of signs and symptoms

- SOB, exertional dyspnea, chronic cough
 Screening at-risk populations
 Evaluation of occupational symptoms

 Abnormal study
- CXR, EKG, ABG, hemoglobin
 Preoperative assessment
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 INDICATIONS — Prognostic

■ Assess severity

■ Follow response to therapy

■ Referral for surgery

■ Disability

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 CLASSIFICATION
A. Non specific tests ( Bed side tests )

B. Specific tests:
a. Tests of ventilation.
b. Tests of diffusion.
c. Tests of perfusion.
d. others.

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 Non specific tests ( Bed side
tests )
1. Sabares breath holding test:
- Patient is asked to take a deep breath & hold it for as
long as possible.
- Normal:> 30 sec ; < 15 sec: decreased ventilatory
capacity.

2. Sneider’s match blowing test:

- A lighted match stick is held 6 inches / 15 cm from the
patients mouth & is asked to blow out the match.
- If patient cannot, MBC < 60L/min & FEV1 < 1.6L. 9
3. Debono’s whistle tests:
- Has a tube with adjustable holes & a whistle at the
end.
- Patient is asked to exhale forcefully into the tube.

4. Auscultation over the trachea:

- Performed during forced expiration.
- Normal: 3- 4 sec.
- > 6 sec: suggestive of obstructive airway disease.

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 Specific tests
Instruments used are:

A. Volume meters: measures the volume of air

inspired or expired.
Ex: Spirometer, Vitalograph.

B. Inferential meters: Volume is measured by the

rate of flow of gases.
Ex: Wright’s respirometer, Pnemotachygraph.
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 Tests of ventilation

1. Static tests:
- Give anatomical measurement of the lungs; but
do not evaluate the function.

Volumes Capacities
- TV - VC
- IRV - TLC
- ERV - IC
- RV - FRC
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LUNG VOLUMES & CAPACITIES

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 Spirometry

- The Spirometry test is performed using a device

called a Spirometer, which comes in several
different varieties.
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- Most Spirometer display the following graphs:
 a volume-time curve, showing volume
(liters) 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

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Procedure:

- The patient is asked to take the deepest breath

they can, and then exhale into the sensor as
hard as possible, for as long as possible.

- During the test, soft nose clips may be used to

prevent air escaping through the nose

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- Used to measure: 4 volumes & 4 capacities.

- Additionally can determine:

- Forced expiratory volume in one second (FEV1)
- Forced vital capacity (FVC)
- FEV1/FVC
- Forced expiratory flow 25%-75% (FEF25-75)

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LUNG VOLUMES

 4 Volumes
 4 Capacities
IRV  Sum of 2 or
IC
more lung
VC
TV volumes
TLC
ERV
FRC
RV RV

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Tidal Volume (TV)
 Volume of air
inspired and
expired during
IRV normal quiet
IC
VC
breathing.
TV  Normal: 6-8ml/kg
TLC
ERV
FRC
RV RV

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Inspiratory Reserve Volume (IRV)

 The maximum
amount of air
that can be
IRV inhaled after a
IC
VC
normal tidal
TV
TLC volume
inspiration.
ERV
FRC  Normal:
RV RV Men- 3.3 L
Women- 1.9L
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Expiratory Reserve Volume (ERV)
 Maximum amount
of air that can be
exhaled from the
resting expiratory
IRV level.
IC
VC  Reflects thoracic &
TV
TLC abdominal muscle
ERV strength.
FRC  Normal:
RV RV
Men - 1.0 L
Women - 0.7L
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Residual Volume (RV)
 Volume of air
remaining in the
lungs at the end
IRV of maximum
IC
VC
expiration.
TV
TLC
ERV  Normal:
FRC Men - 1.2L
RV RV
Women – 1.1L
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Vital Capacity (VC)
 Volume of air that
can be exhaled
from the lungs
after a maximum
inspiration
IRV  FVC: when VC
IC
VC
exhaled forcefully
TV
TLC  VC = IRV + TV +
ERV ERV.
FRC  Normal: 70ml/kg
RV RV
Men – 4.0L
Women – 3.5L
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Inspiratory Capacity (IC)
 Maximum
amount of air
that can be
IRV inhaled from the
IC
VC
end of a tidal
TV
TLC volume
ERV
 IC = IRV + TV
FRC  Normal:
RV RV
Men- 3.8L
Women – 2.4L
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Functional Residual Capacity (FRC)
 Volume of air
remaining in the
lungs at the end of
a TV expiration
 The elastic force of
IRV the chest wall is
IC exactly balanced by
VC the elastic force of
TV
TLC the lungs
ERV  FRC = ERV + RV.
FRC
RV RV
 Normal:
Men- 2.2L 25

Women -1.8L
Total Lung Capacity (TLC)
 Volume of air in the
lungs after a
maximum
IRV inspiration
IC
VC  TLC = IRV + TV +
TV ERV + RV
TLC
ERV
FRC  Normal:
RV RV
Men- 6.0L
Women - 4.2L 26
2. Dynamic tests:

- Measures the rate of ventilation.

- Includes:
a. Maximum breathing capacity.
b. Forced expiratory volume.
c. Peak expiratory flow rate.
d. Maximum mid expiratory flow rate.
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 Measurement:
- Helium dilution method.
- Nitrogen washout
- Body plethsmography

 Indications:
- Diagnose restrictive component
- Differentiate chronic bronchitis from
emphysema
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MAXIMUM BREATHING CAPACITY(MBC):

- Maximum vol. of air that can be breathed per minute

by maximum voluntary effort.
- Normal: 160-180L /min ; < 80% of predicted value is
abnormal.
- Significance:
Post operative dyspnoea & exertional limitation is directly
related to preoperative MBC.
- Decreased in:
Old age, Emphysema, Bronchospasm, Bronchiolar
obstruction.
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FORCED VITAL
CAPACITY (FVC):
- Total volume of air that
can be 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) 30

 FVC
 Interpretation of % predicted:
 80-120% Normal
 70-79% Mild reduction
 50%-69% Moderate reduction
 <50% Severe reduction

FVC
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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 32
 FEV1
 Interpretation of % predicted:
 >75% Normal
 60%-75% Mild obstruction
 50-59% Moderate obstruction
 <49% Severe obstruction

FEV1 FVC

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FORCED
EXPIRATORY FLOW
25-75% (FEF25-75)
- Mean forced expiratory
flow during middle half
of FVC
- Measured in L/sec
- Normal: 4-5 L/sec or
300L/min.
- More sensitive indicator
of small airway
obstruction.
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 FEF25-75
 Interpretation of % predicted:
 >60% Normal
 40-60% Mild obstruction
 20-40% Moderate obstruction
 <10% Severe obstruction

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PEAK EXPIRATORY FLOW RATE ( PEFR )

- Measured by: - Wright’s peak flow meter

- Pneumotachygraph.

- Normal : 450-600L/min ( males )

300-500L/min ( females )

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 Obstructive Pattern

■ Decreased FEV1
■ Decreased FVC

■ Decreased FEV1/FVC
- <70% predicted
■ FEV1 used to follow severity in COPD

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 Obstructive Lung Disease —
Differential Diagnosis

 Asthma
 COPD
- chronic bronchitis
- emphysema
 Bronchiectasis
 Bronchiolitis
 Upper airway obstruction
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 Restrictive Pattern

 Decreased FEV1

 Decreased FVC

 FEV1/FVC normal or increased

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 Restrictive Lung Disease —
Differential Diagnosis

 Pleural

 Parenchymal

 Chest wall

 Neuromuscular
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Spirometry Patterns

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 FLOW-VOLUME LOOP

Ruppel GL. Manual of Pulmonary Function Testing, 8th ed.,

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Mosby 2003
- Provides a graphic analysis of flow at various lung
volumes.

- Used to differentiate b/w patients with upper airway &

lower airway obstruction.

- Flow is charted on X axis & volume on Y axis.

- Patient asked to inhale fully to TLC & then perform

FVC maneuver, followed immediately by a maximum
inspiration back to TLC.

- Ratio of expiratory flow to inspiratory flow at 50% of

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VC = 1
 Upper Airway Obstruction
- Fixed obstruction: benign stricture of trachea,
goiter etc. Mid VC ratio=1

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- Variable Intrathoracic obstruction: tumors
of trachea & major bronchi, foreign bodies, extrinsic
compression etc. Mid VC ratio <1

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- Variable extra thoracic obstruction: vocal
cord palsy, pharyngeal muscle weakness, chr NM
disorders, OSA etc. Mid VC ratio >1

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 TO
SUMMARISE……

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Obstructive Pattern — Evaluation

 Spirometry
 FEV1, FVC: decreased
 FEV1/FVC: decreased (<70% predicted)

 FV Loop “scooped”

 Lung Volumes
 TLC, RV: increased

 Bronchodilator responsiveness 49
 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
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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
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 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
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 DLCO — Indications

 Differentiate asthma from emphysema

 Evaluation and severity of restrictive lung

disease

 Early stages of pulmonary hypertension

 Expensive!
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 Diffusing Capacity

 Decreased DLCO  Increased DLCO

(>120-140% predicted)
(<80% predicted)
 Asthma (or normal)
 Obstructive lung disease
 Pulmonary hemorrhage
 Parenchymal disease
 Polycythemia
 Pulmonary vascular
disease  Left to right shunt

 Anemia
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 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

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 Continued…

SYMPTOMS
↓
PFTs
↓
OBSTRUCTION?
↓ ↓
YES NO
↓ ↓
BRONCHOPROVOCATION
TREAT
↓ ↓
Obstruction? No Obstruction?
TREAT Other Diagnosis
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