Pulmonary Functional Imaging: Basics and Clinical Applications

© Springer Nature Switzerland AG 2021

Y. Ohno et al. (eds.)Pulmonary Functional ImagingMedical Radiologyhttps://doi.org/10.1007/978-3-030-43539-4_1

Anatomical Basis for Pulmonary Functional Imaging

Tomoyuki Hida¹   and Hiroto Hatabu¹

(1)

Center for Pulmonary Functional Imaging, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA

Tomoyuki Hida

Email: [email protected]

1 Introduction

2 Histogenesis

3 Lung Parenchyma

3.1 Lung Alveoli and Alveolar Ducts

3.2 Respiratory Bronchiole

4 Lung Interstitium

4.1 Pulmonary Vessels

4.2 Alveolar Capillary Beds and Venules

4.3 Pulmonary Lymphatics

5 Pulmonary Secondary Lobules

6 Pulmonary Anatomical and Functional Analysis

7 Conclusions

References

Abstract

Respiration is an unconscious but essential activity for us to maintain our lives. Lungs are the organs that play the most important role of gas exchange between blood and air, referred to as external respiration. The function and morphology of the lungs are inseparable and the understanding of pulmonary morphology and microstructure is essential for the interpretation of pulmonary functional imaging fully. In this chapter, we provide radiology- and histology-based lung morphology and correlation with physiology for the understanding of pulmonary functional imaging.

1 Introduction

Respiration is an unconscious but essential activity for us to maintain our lives. Lungs are the organs that play the most important role of gas exchange between blood and air, referred to as external respiration. The abnormalities and diseases of the lungs result in respiratory functional failure with various degrees by the causes. Interstitial pneumonitis (IP) and chronic obstructive pulmonary disease (COPD) are examples of diseases associated with respiratory functional failure. Vascular abnormalities such as pulmonary artery embolism and pulmonary edema with cardiac failure can also have an influence on pulmonary function. Not only these diseases but also pneumonia, atelectasis, tumor, and postoperative changes of the respiratory tract, and even aging, can affect the respiratory function adversely. For exact diagnosis, evaluation of the severity, and following appropriate treatment, assessment of the respiratory function of the patients with the respiratory disorder is important. Spirometry is one of the most useful tools for assessment, which allows us to evaluate obstructive and restricted pulmonary disorder. However, the results depend on the patient’s condition. This test can measure mainly whole lung function, but it is not always enough for detection and evaluation to focal lung functional failure. Lung ventilation-perfusion scintigraphy is also an example and one of the most useful methods of diagnosis for pulmonary embolism, which uses single-photon emission computed tomography (SPECT).

Correspondence between pulmonary function and morphology has been studied, and recent progress of radiological equipment including computed tomography (CT) and magnetic resonance imaging (MRI) shows highly reflection of the pathologic features of lung diseases, and the possibility of future aspects of imaging analysis of pulmonary function (Itoh et al. 2001, 2004; Hatabu et al. 2002). Based on their high resolution and objectivity, these are expected to provide more objective data of pulmonary function and may refer localization of the respiratory disorder on the order of much smaller than subsegment (Webb 2006; Nishino et al. 2014). The function and morphology of the lungs are inseparable and the understanding of pulmonary morphology and microstructure is essential for the interpretation of pulmonary functional imaging fully. In this article, we provide radiology- and histology-based lung morphology and correlation with physiology for the understanding of pulmonary functional imaging.

2 Histogenesis

Lungs are a pair of spongy organs, which are air-filled and work for gas exchange between blood and air. The lungs are made up of numerous microstructures including bronchiole, alveolar duct, alveoli (called parenchyma), interalveolar septa, pulmonary vessels, bronchial artery, and lymphatics (called non-parenchyma). The characteristic structures of the lung are the result of millions of years of evolution.

Lungs develop from endoderm and mesoderm (Schoenwolf et al. 2014; Schittny 2017; Mullassery and Smith 2015). Endoderm is lining the respiratory diverticulum and gives rise to the epithelium and glands of trachea, bronchi, bronchiole, and alveoli. The connective tissue, cartilage, airway and vascular smooth muscles of the lungs are derived from the surrounding splanchnic mesoderm. Lung development and maturation can be divided into pseudoglandular, canalicular, saccular, and alveolar phases. Lung buds proliferate and branch in the surrounding splanchnic mesenchyme during pseudoglandular phase, and branching continues until all of the segmental bronchi have been formed. All major lung structures involved in the airway are formed by the end of this phase. Then, canaliculi, which compose the proper respiratory part of the lungs, branch out of the terminal bronchioles. In this canalicular phase, the terminal bronchiole divides to form several respiratory bronchioles, and consequently these respiratory bronchioles divide into several alveolar ducts. Alteration of the epithelium and the surrounding mesenchyma is also seen. The capillaries begin to invade into the mesenchyma and surround the acini. In the lumen, the cuboidal epithelial cells lining the respiratory structures differentiate into type I and type II pneumocytes. Type I pneumocytes line most of the inner surface area of the alveolar ducts and sacculi and type II pneumocytes begin to secrete small amounts of surfactant. First future air-blood barriers are formed during this phase and fetal breathing movements may begin. Then, the terminal airways grow in length and width and form saccules, which represents the last subdivision of the passages that supply air. This saccular phase sees thinning of connective tissue between the airspaces and further maturation of the surfactant system. After that, the formation of secondary septa, which divides alveolar ducts into terminal alveoli, is seen in the final stage of lung development. Microvascular maturation also occurs in parallel to alveolarization. This alveolar phase, which maximizes the gas exchange surface area, begins in the last few weeks of the pregnancy and continues until 8–10 years postnatally (Mullassery and Smith 2015).

3 Lung Parenchyma

3.1 Lung Alveoli and Alveolar Ducts

Lung parenchyma is the component for gas exchange and usually includes alveoli, alveolar ducts, and respiratory bronchioles (Schoenwolf et al. 2014). Acinus is the most important unit of pulmonary function that refers to all the lung parenchyma distal to the terminal bronchiole, and usually has 2–5 generations of respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli. Figure 1 reveals numerous air-containing passages and intervening fine structures, corresponding to alveolar duct and alveoli, respectively. The airways have approximately 23 generations of dichotomous branching from the trachea to alveoli. Central bronchioles can be identified up to eighth or older by high-resolution CT. There are 300–500 million alveoli in the lungs of a human adult, with a combined internal surface area of approximately 75 m², which is roughly the same size as a tennis court (Rhoades and Bell 2017). The overall shape of alveoli is polyhedral, and 7–8 alveoli surround the alveolar ductal lumen (Fig. 2). The interalveolar septum is seen between adjacent alveoli.

Fig. 1

A low power magnified view of the specimen shows a secondary lobule, in which the bronchiole locates in the center, and pulmonary veins and interlobular septa distribute in the boundary. Large cavities constitute alveolar ducts, and the smaller ones are alveoli. (Adapted with permission from reference Itoh et al. (2001))

Fig. 2

A magnified view of the specimen shows alveolar ducts and alveoli. The alveoli show a polygonal shape and have orifices into alveolar ductal spaces. (Adapted with permission from reference Itoh et al. (2001))

The detailed structure of alveoli and alveolar ducts has been written by Itoh et al. (2001, 2004). Histologically, every alveolar septal membrane appears as a line. Three-dimensionally, it is possible to distinguish alveolar ductal lumen, alveolar entrance, the lateral wall of the alveolus, and dome of the alveolus. The diameter of the ductal lumen is 0.3 mm, and the mean size of the alveolus is 0.2 mm. The alveolar duct length is about 1 mm in the long axis. The inner surface of the alveolar duct is covered by a sheet of alveoli. The shape of each alveolar entrance is polygonal like a honeycomb, which is ideal for maximizing cell volume in a limited space. The honeycomb structure is composed of a single layer of alveoli, but in the lung parenchyma, the alveoli walls are double-layered. Every lateral wall of the alveolus joins to the apex of the alveolar dome. The double-layered alveolar sheets hold alveolar domes in common. This common histologic image defines the two-dimensional architectural unit of lung parenchyma. A small hole called Kohn pore can be seen in the alveolar dome. The alveolar ducts are characterized by frequent branching, and the pattern of branching is different from that of a bronchiole, as there is no spur. Histologically, there is an architectural unit forming a network in the parenchymal space and surrounding the alveolar duct (Fig. 3). The lumen of the alveolar duct is surrounded by polygonal alveoli, and the overall shape of the alveolar duct is polygonal, while the overall shape of the similarly sized bronchiole is cylindrical. This implies that the alveolar duct has an ideal overall shape for maximizing lung function. The histologic image in Fig. 3 demonstrates that the number of alveolar ducts is much greater than that of the bronchioles.

Fig. 3

A histological section shows a number of alveolar ducts with transition from the bronchiole. A greater number of alveolar ducts are seen compared with that of bronchioles. A part of the interlobular septa is seen in the periphery. (Adapted with permission from reference Itoh et al. (2001))

3.2 Respiratory Bronchiole

Respiratory bronchiole is usually included in lung parenchyma and called the transitional zone (Itoh et al. 2001, 2004). It is because the wall is partly replaced by alveoli and contributes gas exchange. Respiratory bronchioles split into several alveolar ducts, which terminate in alveolar sacs and individual alveoli (Fig. 4). The distance is constant from the respiratory bronchiole to the nearest septal structures of the secondary lobule. The wall of the respiratory bronchiole is remote from the pulmonary artery and is replaced by a double sheet of alveoli where they abut the recurrent branch of the alveolar duct.

Fig. 4

A contact radiograph shows terminal and respiratory bronchioles with alveolar ducts opacified with barium sulfate. The alveoli have orifices into the respiratory bronchioles. (Adapted with permission from reference Itoh et al. (2001))

4 Lung Interstitium

4.1 Pulmonary Vessels

There are two circulatory systems of blood supply in the lungs: pulmonary and bronchial vessels. Pulmonary arteries are located in the center of secondary lobules together with bronchioles that run parallel to them, while pulmonary veins are located in the margins of the lobules together with interlobular septa (Figs. 5 and 6). On CT images, pulmonary arteries of 200–300 μm in diameter are visualized. Figures 7 and 8 show numerous small lateral branches of bronchi besides the regular dichotomous pattern of branching. There are a greater number of pulmonary artery branches than lateral branches of bronchi. The fact indicates that there could be small pulmonary artery branches that are not accompanied by bronchi. However, the pulmonary arteries must be accompanied by bronchioles in distant areas of the peripheral region. Bronchial circulation provides a rich blood supply to the bronchi, large vessels, hilar lymph nodes and visceral pleura from bronchial arteries and communicating vessels between the pulmonary vein and the bronchial venous plexus. Bronchial veins are located around a bronchoarterial sheath, which communicates directly with the adjacent pulmonary vein, which gives off a small branch to the neighboring airways.

Fig. 5

A radiograph of 1-mm-thick specimen shows the secondary lobules, of which pulmonary arteries are located in the center and pulmonary veins are in the periphery. Terminal and respiratory bronchioles are observed as tubular structures accompanying the pulmonary arteries. Alveolar regions are visualized as fine reticular opacities. (Adapted with permission from reference Itoh et al. (2001))

Fig. 6

A fixed specimen of a resected fixed lung specimen obtained during surgery shows bronchus and pulmonary artery (right upper) and pulmonary vein (left lower). A pulmonary vein connecting them (arrow) is observed, which receives blood from the alveolar region. (Adapted with permission from reference Itoh et al. (2001))

Fig. 7

A pulmonary arteriography with barium sulfate demonstrates a great number of small lateral branches originating from bronchi besides the regular dichotomous pattern of branching. (Adapted with permission from reference Itoh et al. (2001))

Fig. 8

A pulmonary arteriography using a higher concentration of barium sulfate than in Fig. 9 visualizes pulmonary arteries which run through the center of secondary lobules. The edges of the secondary lobules are partially opacified. (Adapted with permission from reference Itoh et al. (2001))

4.2 Alveolar Capillary Beds and Venules

Figure 9 shows the alveolar capillary, which is one of the important structural components of the interalveolar septum (Itoh et al. 2001, 2004). The capillary beds extend to 50% of the volume of the septum. The alveolar capillary shows a dense network which is composed of a number of irregular polygons. 10% of alveoli meet non-parenchymal structures, such as pulmonary vessels (Weibel 1979). A number of alveoli abut the pulmonary vein. Because gas diffusion does not occur towards the pulmonary vessel, the alveolar dome contiguous to the vessel is a single-faced alveolar wall, instead of usual double-layered sheets. In contrast, the interalveolar septum is a double-faced alveolar wall, which enables gas exchange on both sides. As blood flows through the capillaries, oxygen diffuses from the alveolar space into the blood in conjunction with carbon dioxide diffusing from the blood into the alveolar space. Alveolar capillaries are connected to post- or pre-capillary small vessels. These small vessels occupy part of the limited interstitial space between the alveolar ducts and typically are located in the corner where four alveolar ducts gather. This corner called a ridge in solid geometry is ideal for blood vessel distribution.

Fig. 9

A radiograph of 300-μm-thick specimen shows alveolar capillary vessels filled with barium sulfate. Capillary vessels reside in the alveolar walls. (Adapted with permission from reference Itoh et al. (2001))

4.3 Pulmonary Lymphatics

Pulmonary lymphatics defend the lungs from airborne particles and microorganisms and allow a local influx of liquid to clear and clean inflamed or damaged tissue (Schraufnagel 2010). Figures 10 and 11 show the distribution of pulmonary lymphatic channels (Itoh et al. 2001). They distribute centrally along with the bronchovascular bundle towards the center of the lobules and peripherally within the interlobular septa and subpleural pulmonary tissues, but are not seen in the alveolar region. Subpleural lymphatic structures are sandwiched between air and lung parenchyma (Itoh et al. 2004). Three-dimensional CT demonstrates a rich network of lymphatics as a number of polygonal patterns (Figs. 12 and 13). As the reticular and linear structures of lymphatics are on the pulmonary side of the pleura, the lung surface is smooth while it appears to be irregular (Fig. 14). The size of the lymphatic systems expands to a varying degree in response to such conditions as an excess fluid load, cancer, or inflammation.

Fig. 10

The figure shows the distribution of pulmonary lymphatics. The pulmonary lymphatics do not exist in the alveolar region. Br, bronchus; ILS, interlobular septa; PA, pulmonary artery; PV, pulmonary vein. (Adapted with permission from reference Itoh et al. (2001))

Fig. 11

The figure shows lymphatics (green) and bronchial artery circulation (red) in the bronchial wall. The structures around the pulmonary artery are also described. (Adapted with permission from reference Itoh et al. (2001))

Fig. 12

A three-dimensional computed tomography of a resected left upper lobe obtained during surgery shows interlobular septa and lymphatics located on the surface of the lung. Pleural indentation caused by lung adenocarcinoma is observed. (Adapted with permission from reference Itoh et al. (2001))

Fig. 13

An inflated, unfixed right lower lobe obtained during a surgical resection (left) and a corresponding three-dimensional computed tomography (3D-CT, right). The polygonal pattern is consistent between specimen and 3D-CT. Although the lung surface looks irregular, it is smooth because the polygonal pattern is a subpleural structure. (Adapted with permission from reference Itoh et al. (2001))

Fig. 14

The axial computed tomography corresponding to Fig. 6 demonstrates pulmonary arteries in the center of the secondary lobules (arrows), and pulmonary veins and interlobular septa in the periphery. (Adapted with permission from reference Itoh et al. (2001))

5 Pulmonary Secondary Lobules

The lungs are made up of such various and numerous anatomical microstructures, and there is a limitation to describe all of these microstructures in even recent radiological equipment. Therefore, secondary nodules are the basic and most important unit used for diagnosis and functional analysis of the lungs (Webb 2006; Nishino et al. 2014). This is the key to high-resolution CT terminology, and also the key to an understanding of the correlation between pulmonary morphology and function.

Secondary lobules measure between 1 and 2.5 cm in diameter and are composed of 5–15 acini and 30–50 primary lobules (Webb 2006). They are irregularly polyhedral in shape bounded by the interlobular septa that are continuous with the peribronchovascular interstitium and pleura (Fig. 15). Each secondary lobule is supplied by a lobular bronchiole and a pulmonary artery branch in the center and is drained by the pulmonary veins that form in the periphery of the lobule and pass through the interlobular septa (Fig. 16). Pulmonary lymphatics also run within the interlobular septa. Interlobular septa are at the lower limit of thin-section CT resolution. Under normal conditions, a few of these thin septa are visible in the lung periphery, usually anteriorly or along mediastinal pleural surfaces, but tend to be inconspicuous. Lung diseases have been classified with relation to the anatomy of the secondary lobules based on radiologic-pathologic correlation (Webb 2006; Nishino et al. 2014). Pathologic alterations in secondary lobular anatomy include interlobular septal thickening and diseases with peripheral lobular distribution, centrilobular and panlobular abnormalities, which can be visualized on thin-section CT scans. The recognition and analysis of which component of the secondary lobule is involved help us to diagnose the lung abnormalities and to narrow the differential diagnosis in such as diffuse lung diseases.

Fig. 15

A magnified view of the specimen shows interlobular septa, which is rarely exposed in the plane because the cut direction is parallel to the septa. (Adapted with permission from reference Itoh et al. (2001))

Fig. 16

A fixed specimen shows secondary lobules, of which bronchioles and pulmonary arteries are seen in the center, and pulmonary veins and interlobular septa are located in the margins. (Adapted with permission from reference Itoh et al. (2001))

6 Pulmonary Anatomical and Functional Analysis

An understanding of lung morphology and their ultrastructures that are believed to contribute for the pulmonary function is necessary and essential for effective pulmonary functional imaging. Assessment of pulmonary function by using radiological imaging has been tried for many years. As one of the examples of pulmonary functional imaging, pulmonary ventilation and perfusion SPECT using 81 m Kr and 133 Xe gases is still one of the most effective examinations for evaluation of pulmonary embolism and obstructive pulmonary diseases. Recent development in radiology such as CT and MR imaging technology allows investigating different aspects of lung function, such as ventilation, perfusion, gas exchange, and respiratory mechanics from these morphological images. These techniques are useful not only for diagnosis but also for evaluation of severity, cause, and factors of lung diseases.

Recent development of CT equipment makes it possible to describe the detail of pulmonary morphology (Kakinuma et al. 2015). In the future, high-resolution CT imaging may describe the detail of microstructures smaller than acini. The morphological analysis on chest CT images may also make it possible to analyze the functional analysis of the lungs. As is well known, analysis for low attenuation area on chest CT images is very useful for diagnosis of emphysema. Inhalation/exhalation CT imaging is one of the most useful tools to evaluate respiration activity (Matsuoka et al. 2008; Koyama et al. 2016). Combination of inhalation and exhalation CT images makes it possible to visualize focal respiration such as ground-glass opacities that reflects an amount of air in secondary nodules or acini and air trapping which reflects obstruction of the bronchiole. These findings are useful for diagnosis and evaluation of severities of lung diseases such as hypersensitivity pneumonia, obstructive bronchitis, and COPD. Dual-energy CT, which utilizes two separate energy sets to examine the different attenuation properties of matter, having a significant advantage over traditional single energy CT, may make it possible to evaluate the focal pulmonary function with iodine-distribution imaging (Lapointe et al. 2017). Quantification of the respiratory activity of the lung using CT images and comprehension of segmental respiratory function is also useful for radiation therapy (Faught et al. 2017). Radiation therapy avoiding the high respiratory function area will reduce normal lung damages and be effective for tumor treatment. Radiation pneumonitis will be also avoided better by using pulmonary functional imaging.

Another aspect of pulmonary function, pulmonary perfusion analysis is also important and can be also evaluated by CT imaging. The analysis is useful not only for the detection of focal changes of pulmonary perfusion in such as pulmonary embolism but also for differential diagnosis of pulmonary nodules (Ohno et al. 2015). In a sense, visualization of pulmonary vessels for surgery may be included in the so-called functional imaging.

The recent revolutionary development of MR imaging techniques has opened a new window for the functional assessment of the lungs. MR imaging has become a feasible modality for the functional assessment of the lung including perfusion, ventilation, and biomechanics. Hyperpolarized gas image acquisition of MR imaging by using such as 129-Xenon and 3-Helium has been used to visualize the status of gas distribution and ventilation of airways and alveoli (Liu et al. 2014). These analyses will be used for evaluation of ventilation disorder such as pulmonary emphysema and bronchial asthma. It has been reported that there is a correlation between O2-enhanced MR imaging, and forced expiratory volume in a second and diffusion ability (Ohno et al. 2011). O2-enhanced MR imaging is applied for evaluation of pulmonary emphysema and bronchial asthma and may be also used for the prediction of the postoperative pulmonary function for lung cancer patients.

Dynamic analysis of the lungs is also one of the progress of pulmonary functional imaging (Yamada et al. 2017). Dynamic chest X-ray imaging reveals the movement of the diaphragms in the respiration and may be also useful for the analysis of pulmonary function. This method can be achieved at standing or sitting position and is thought to be useful for dynamic analysis of the lungs in normal condition, compared to CT and MR images that need lying position for imaging. About lungs, construction of the lungs is thought to be uneven—for example, surface towards ribs moves smoothly, and surface towards diaphragm moves bigger than any other sites. The analysis of the kinetics of the lungs will be also useful for the diagnosis and evaluation of various lung diseases.

7 Conclusions

Lung function is inseparable from its characteristic architecture, namely pulmonary alveolar structures. Knowledge of the morphology of the lungs is essential for understanding the morphologic-functional relationship of the lungs and for effective pulmonary functional imaging.

Acknowledgments

This chapter is written based upon the author’s previous collaborative works with Professor Harumi Itoh, a great chest radiologist and an educator. This chapter is dedicated to Dr. Harumi Itoh, an emeritus professor and the first dean of School of Medical Sciences, Fukui University.

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© Springer Nature Switzerland AG 2021

Y. Ohno et al. (eds.)Pulmonary Functional ImagingMedical Radiologyhttps://doi.org/10.1007/978-3-030-43539-4_2

Pulmonary Function Tests

Toyohiro Hirai¹  

(1)

Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan

Toyohiro Hirai

Email: [email protected]

1 Introduction

2 Spirometry

3 Lung Volumes

4 Diffusing Capacity

4.1 Measuring Method

4.2 Interpretation of DLCO

5 Other Pulmonary Function Tests

5.1 Reversibility Test

5.2 Bronchoprovocation Test

5.3 Arterial Blood Gas Analysis

5.4 Respiratory Impedance

5.5 Field Walking Tests

5.6 Clinical Assessment of Dyspnea

6 Summary

References

Abstract

Pulmonary function tests provide quantitative assessment of physiological properties in respiratory system including the lungs and chest wall. Spirometry is the first step as a screening and diagnostic test to investigate the existence and severity of obstructive or restrictive ventilatory disorders. Second is the measurement of lung volumes. Another technique is used to measure functional residual capacity, because absolute gas volume remaining in the lungs cannot be measured using spirometer. Measurements of lung volumes enable us to evaluate the changes in the mechanical balance between the lungs and chest wall, due to pulmonary or extrapulmonary diseases. As the next step, diffusing capacity for carbon monoxide can be measured to assess the capacity of the lung to exchange gas across the alveolar-capillary interface. Arterial blood gases that reflect the final output from respiratory system as the organs for gas exchange are introduced for the diagnosis of respiratory failure and acid-base disturbances. Additional pulmonary function tests including bronchoprovocation test, the measurement of respiratory impedance, and field walking tests (the 6-min walk test, incremental shuttle walk test, and endurance shuttle walk test) may be performed for further examinations in specific clinical circumstances. All these pulmonary function tests are useful for the assessment of pulmonary diseases in the clinical settings and clinical researches, especially in conjunction with morphological assessment using image diagnosis.

1 Introduction

Pulmonary function tests have the following characteristics compared with image diagnosis: they provide physiological characteristics of the lungs as quantitative values, and they are useful for the assessment of the disease severity, changes in functions during disease process, indication and effects of therapy, and also comparison with healthy subjects using the predicted values. Generally, pulmonary function tests reveal the parameters of physiological function for whole lungs, and do not describe the specific locality of the diseased area, while image diagnosis is able to provide normal and diseased areas visually. However, pulmonary function tests must contribute to the understanding of pathophysiology in pulmonary diseases, especially in conjunction with image diagnosis.

Table 1 shows major pulmonary function tests. They consist of measurements to evaluate pulmonary function including ventilation and gas exchange. In this section, some of basic function tests will be described to be useful for the understanding of functional imaging.

Table 1

Major pulmonary function tests

2 Spirometry

Spirometry is the most classical and basic test of pulmonary function. It can be easily introduced and has been widely performed in usual clinical settings. Spirometer is simple equipment to measure and record changes of mouth flow with time, and the volume is calculated by integral of the flow. All spirometric measurements should be performed according to the official statement (Pellegrino et al. 2005; Miller et al. 2005) of the American Thoracic Society (ATS) and the European Respiratory Society (ERS) that describes the issues for standardization of spirometry including requirements for equipment, and within- and between-maneuver evaluation. At least three acceptable maneuvers are necessary to obtain accurate measurements.

For the measurements using spirometer, there are two kinds of maneuvers, slow and forced vital capacity maneuvers (SVC and FVC maneuver, respectively). SVC maneuver is performed to evaluate static characteristics of lungs by measuring lung volumes including vital capacity (VC). Figure 1 shows time tracing of lung volume in SVC maneuver. Decreased VC less than lower limit of the normal range (or 80% of predicted value) is defined as restrictive ventilatory impairment (Table 2). On the other hand, FVC maneuver provides the characteristics of dynamic ventilation including forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) (Fig. 2). FEV1/FVC less than lower limit of normal (or 0.7) is defined as obstructive ventilatory impairment (Table 2). Figure 3 shows various patterns of ventilatory impairments with reduced FEV1 in forced expiration. Low FEV1 derives from obstructive, restrictive, or both ventilatory impairments. It is noted that the patients with severe COPD (severe emphysema) show low FEV1 with reduced FVC as described later (see Sect. 3).

Fig. 1

Time tracing of lung volume in slow vital capacity (SVC) maneuver. After stable tidal breathing repeated several times, maximum inspiration after complete expiration, and maximum expiration again are slowly performed, and then the subject can relax back to tidal breathing. Lung volumes consist of four basic volume fractions: IRV, TV, ERV, and RV, whereas capacities are compartments composed of two or more volumes. TV (tidal volume): the volume of air entering and leaving the lungs during breathing at physiologic rest; IRV inspiratory reserve volume; ERV expiratory reserve volume; RV (residual volume): the volume of air that remains in the lungs due to the collapse of all small airways after maximum expiration; VC (vital capacity) = ERV + TV + IRV. FRC (functional residual capacity) = RV + ERV: the volume of air remaining in the lungs after a normal, physiologic expiration. IC (inspiratory capacity) = TV + IRV. TLC (total lung capacity) = RV + ERV + TV + IRV: the total volume of the lungs at maximal inspiration

Table 2

Typical examples of ventilatory disorders

Fig. 2

Time tracing of lung volume in forced expiration, where expiation starts at time 0. FEV1 forced expiratory volume in 1 s, FVC forced vital capacity. The subject requires forced expiration for 6 s or more

Fig. 3

Comparison of time tracings of lung volume in forced expiration among various ventilatory impairments. Expiation starts at time 0. a: normal, b: obstructive impairment (e.g., COPD), c: restrictive impairment (e.g., pulmonary fibrosis), d: mixed impairments of obstruction and restriction, or severe obstructive impairment (e.g., severe COPD)

Flow-volume curve is another description in FVC maneuver (Fig. 4). This curve provides several parameters such as peak expiratory flow and the mean forced expiratory flow between 25% and 75% of the FVC (FEF25–75%). However, it is more important to recognize the shape of the curve, because some lung diseases provide different and typical patterns of the flow-volume curves (Fig. 5). In patients with COPD, a concave shape is typical on the flow–volume curve with a proportionally greater reduction in FEF75%. On the other hand, the flow–volume curve in patients with pulmonary fibrosis shows a convex pattern with a reduced VC and a normal or slightly increased FEV1/FVC. The flow-volume display is also useful for checking whether the maneuver has performed properly.

Fig. 4

Schematic explanation of flow-volume curve in FVC maneuver

Mean forced expiratory flow between 25% and 75% of FVC is known as FEF25–75%. PEF peak expiratory flow, FEFX% instantaneous forced expiratory flow when X% of the FVC has been expired, TLC total lung capacity, RV residual volume, FVC forced vital capacity

Fig. 5

Typical examples of flow plotted against absolute lung volume in healthy subject and patients with obstructive or restrictive lung diseases. a; normal, b: COPD, c: bronchial asthma, d: pulmonary fibrosis

Spirometric measurements are dependent on many factors including age, gender, height, and race. Thus, reference values (equations) that are derived from large groups of healthy subjects can be used to compare the measurements among patients or subjects with different age and height using percent of predicted values. Ideally, race-specific reference values (equations) should be used. Percentage of predicted values is also used for the evaluation of disease severity. For example, severity of airflow limitation in COPD suggested by Global Initiative for Chronic Obstructive Lung Disease (GOLD) is classified on the basis of percent predicted value of post-bronchodilator FEV1 (Table 3) (available at https://​goldcopd.​org/​gold-reports/​). This classification derives from the fact that FEV1/FVC may not reflect the disease severity because not only FEV1 but also FVC can decrease in the patients with advanced COPD.

Table 3

Severity of airflow limitation in COPD (GOLD classification)

GOLD Global initiative for chronic obstructive lung disease

3 Lung Volumes

Lung volumes can be determined by the mechanical balance between the lungs and chest wall, which is the relationship between pressure-volume curve of the lungs and that of the chest wall. To evaluate the lung volume fractions is useful for the diagnosis and understanding of pathophysiology in pulmonary diseases.

Spirometry is not able to provide total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV), because spirometer can measure the volume of air entering and leaving the lungs, and it is not possible to measure absolute volume of air remaining in the lungs. Thus, other tests are necessary, and usually the measurement of FRC is introduced (Wanger et al. 2005). Once FRC is determined, TLC and RV can be calculated using FRC and spirometric parameters. Table 4 shows the methods for the measurement of FRC. Gas dilution method is the test using a known volume and fraction of gas (Helium (He) or Nitrogen), which is not nearly absorbed in blood, as a tracer gas. This test may not reflect the volume of air in the poorly ventilated areas (e.g., bulla) of the lungs during tidal breathing. On the other hand, body plethysmograph can measure whole thoracic gas volume including the poorly ventilated areas of the lungs, and generally FRC measured using body plethysmograph is more than that using gas dilution method in the patients with lung diseases such as severe COPD and large bullae. Measurements of TLC using body plethysmograph correlate well with those measured by chest computed tomography when the subject holds his breath after maximum inspiration during the scan.

Table 4

Methods for measurement of functional residual capacity (FRC)

aThe lung volume (FRC) at the time the subject is connected to the closed circuit with a known gas volume (V1) and helium fraction (F1) is calculated from the helium fraction at the time of equilibration (F2) as follows:

V1 × F1 = (V1 + FRC) × F2

FRC = V1 (F1 − F2)/F2

because helium gas is not nearly absorbed in blood

bThe subject breaths 100% oxygen through one-way valve to wash out the nitrogen (N2) from the lungs, and the expired gas is collected to measure the volume and N2 fraction. The lung volume at the start of washout (FRC) is calculated using the initial alveolar N2 concentration and the amount of N2 washed out

cThe subject is seated inside a whole-body plethysmograph (so-called body box) and breaths through a mouthpiece with pneumotachograph. The thoracic gas volume (FRC) can be calculated using the changes in mouth pressure and plethysmograph (box) pressure on the basis of Boyle’s law

Figure 6 shows typical examples of lung volumes in healthy subject and patients with obstructive or restrictive lung diseases, though the details in changes of lung volumes may vary with disease severity in each patient. In elderly subjects, RV and FRC increase with age, but TLC remains stationary, and consequently VC decreases. In severe obesity, RV remains within normal limits, whereas significant decrease in FRC is seen as body mass index (BMI) increases. Restrictive lung diseases such as pulmonary fibrosis show that lung volumes are all decreased as a result of restricted expansion. Respiratory muscle weakness such as neuromuscular diseases increases RV and decreases TLC and VC. In obstructive lung diseases such as COPD, RV and TLC increase reflecting pulmonary hyperinflation as a result of air trapping. In severe emphysema, TLC does not increase as much as increase in RV as the result that VC and IC decrease.

Fig. 6

Typical examples of lung volumes in healthy subject and patients with obstructive or restrictive lung diseases. VC vital capacity, IC inspiratory capacity, RV residual volume, FRC functional residual capacity, TLC total lung capacity

4 Diffusing Capacity

The test of diffusing capacity reflects the function of gas exchange in the lung. Atmospheric gas is transferred from inhaled air to blood in pulmonary capillaries across the thin membrane (0.2–0.3 μm) of alveolus by diffusion according to the gradient of gas concentration. The amount of gas transferred is proportional to the surface area and the difference in partial pressure of gas, and is inversely proportional to the thickness of the alveolar-capillary membrane (Fig. 7).

Fig. 7

Schematic explanation of diffusing capacity. P1, P2: partial pressure of gas in alveolus and capillary, respectively. The difference between P1 and P2 is the driving pressure for diffusion. RBC red blood cell, Hb hemoglobin

4.1 Measuring Method

To assess diffusing capacity, carbon monoxide (CO) is usually used as a tracer gas, because CO content in venous blood can be neglected and CO has high affinity with hemoglobin. The single-breath method (Fig. 8) (Macintyre et al. 2005; Graham et al. 2017a, b) is commonly used to obtain diffusing capacity for carbon monoxide (DLCO), which is the volume of CO transferred in milliliters per minute per mmHg of alveolar partial pressure. During 10-second breath holding after full inspiration of test gas including known concentrations of CO and He, CO can be transferred to blood in pulmonary capillaries. Transfer coefficient of the lung (KCO) is measured as a concentration fall in alveolar CO per minute per partial pressure of CO. Alveolar volume (VA) is obtained from the changes in He gas concentration, and finally DLCO is calculated as the product of KCO and VA.

Fig. 8

Single breath DLCO maneuver. After a maximum expiration to residual volume (RV), the subject inhales the test gas (0.3% CO, 10% helium, oxygen, and nitrogen) rapidly to total lung capacity (TLC), and holds his breath for 10 s. During this breath holding, the partial pressure of CO in alveolar gas can be decreased as transferring CO to red blood cells in pulmonary capillaries. An alveolar sample of the exhaled gas is collected after dead space washout (0.75–1.0 L) to measure the fractions of CO and He gas. He gas is used to calculate the alveolar volume (VA)

It should be noted that this method may not be able to apply for the patients with low VC and severe lung disease because of the requirement of 10-second breath holding and expired lung volume for washout and sample collection, though recent advanced equipment can improve DLCO measurement by the continuous measurement technology using rapidly responding gas analyzer (Graham et al. 2017a, b).

4.2 Interpretation of DLCO

The measured DLCO can be affected not only by alveolar surface area and thickness but also by the volume of blood and the concentration of hemoglobin (Hb) in pulmonary capillaries (Table 5). Thus, DLCO is also known as the transfer factor for carbon monoxide (TLCO), because the measured value does not solely reflect the diffusing properties of the lung. In COPD patients, the extent of low attenuation area on chest CT images, which reflects pulmonary emphysema, correlates well with DLCO (Morrison et al. 1989; Gould et al. 1991). In interstitial pulmonary fibrosis, DLCO has significant correlation with the disease prognosis (Plantier et al. 2018). Patients with combined pulmonary fibrosis and emphysema (CPFE) show the significant reduction of DLCO, with the preservation of spirometric values and lung volumes that derive from a counterbalance between the restrictive effects of pulmonary fibrosis and the hyperinflation by emphysema (Papaioannou et al. 2016). The restrictive ventilatory disorders by spirometry with normal DLCO may suggest extrapulmonary causes such as neuromuscular disease and pleural thickening. High DLCO is associated with asthma, obesity, and intrapulmonary hemorrhage.

Table 5

Clinical examples of low diffusing capacity (DLCO)

Here, it is important to interpret the measured values of DLCO in conjunction with KCO. Although KCO is mathematically equal to DLCO/VA, DLCO/VA does not represent the correction for alveolar volume. It should be noted that DLCO depends not only on alveolar volume but also on pulmonary blood flow. In pulmonary emphysema, both DLCO and DLCO/VA are decreased, while in patients who have undergone lung resection (e.g., pneumonectomy) and have the healthy remaining lung, DLCO is decreased and DLCO/VA is increased because of the increase in blood flow per alveolar unit.

5 Other Pulmonary Function Tests

5.1 Reversibility Test

Spirometry before and after bronchodilator [inhalation of β2-stimulant (e.g., albuterol)] is used to evaluate the degree of airway reversibility. An increase in FEV1 of more than 12% and greater than 0.2 L suggests significant bronchodilator responsiveness. Airway reversibility is one of the typical characteristics in asthmatic patients, though significant bronchodilator responsiveness cannot clearly discriminate between asthma and COPD.

5.2 Bronchoprovocation Test

Spirometry before and after bronchoprovocation challenges (e.g., inhaled methacholine of a starting delivered dose of 1–3 μg with subsequent doubling or quadrupling steps) is used to assess the airway hyperresponsiveness (AHR) (Coates et al. 2017). AHR is defined as an increased sensitivity and exaggerated response to nonallergenic stimuli to cause airway narrowing, and is most commonly associated with asthma. Airway response is categorized from normal to marked AHR using the delivered dose of methacholine causing a 20% fall in FEV1 (provocative dose (PD20)).

5.3 Arterial Blood Gas Analysis

Arterial blood gas analysis is useful for the assessment of respiratory failure and acid-base disorders. Hypercapnia (PaCO2 > 45 Torr) reflects alveolar hypoventilation, because PaCO2 is inversely proportional to alveolar ventilation.

5.4 Respiratory Impedance

Recently, the measurement of respiratory impedance using forced oscillation technique (FOT) (Oostveen et al. 2003) is widely used for physiological assessments, mainly of obstructive diseases such as bronchial asthma and COPD. Respiratory impedance, including resistance and reactance, can be measured using the relation between airway opening pressure and flow by imposing oscillation signals on normal breathing. Major component of respiratory resistance is airway resistance, whereas reactance reflects the elastic and inertial properties. Compared with spirometry, FOT is useful for the functional assessment of lung diseases especially for childhood asthma and adult severe COPD, because the FOT enables us to measure respiratory mechanics during tidal breathing without requiring an effort-dependent maneuver such as forced expiration. For example, the patients with asthma attack show the impedance values with increase in resistance and decrease in reactance, and they recover to normal ranges after inhalation of bronchodilator.

5.5 Field Walking Tests

Spirometry, measurements of lung volumes, and DLCO as described above are all the tests for the subject at rest. Field walking tests (Holland et al. 2014; Singh et al. 2014) such as the 6-min walk test, incremental shuttle walk test, and endurance shuttle walk test are useful for evaluating functional exercise capacity in chronic respiratory disease. These tests can provide additional information on spirometry. For example, the patients with interstitial fibrosis often show oxygen desaturation and dyspnea on exercise even with normoxia at rest. The 6-min walking distance (6MWD) correlates more strongly with measures of peak work capacity and physical activity than with respiratory function, and shorter 6MWD correlates with an increased risk of mortality for patients with COPD, interstitial lung disease, and pulmonary hypertension.

5.6 Clinical Assessment of Dyspnea

Dyspnea is one of the common symptoms in patients with pulmonary diseases. Several questionnaires are available to assess the severity of dyspnea, such as the visual analog scale (VAS), the Borg scale (rating from 0 (Nothing at all) to 10 (Very, very severe)) (Borg 1982), and the Modified Medical Research Council (mMRC) dyspnea scale (Fletcher 1960) (Table 6). These scales can be used to evaluate the severity of dyspnea in baseline and future changes, for example, before and after exercise or medical treatment in chronic respiratory diseases.

Table 6

Modified Medical Research Council (mMRC) dyspnea scale

6 Summary

In this section, common pulmonary function tests are briefly overviewed. The VC, FEV1, and FEV1/FVC ratio measured by spirometer are the basic parameters used to interpret lung function and classify into normal, obstruction, restriction, or mixed defect. The measurement of lung volumes can provide additional information to evaluate ventilator defect. For the next step, it is important to measure DLCO. The measurement of DLCO is useful to assess the causes of dyspnea or hypoxemia. Low DLCO suggests gas exchange abnormalities such as COPD (emphysema), interstitial lung diseases, and pulmonary vascular diseases. All these pulmonary function tests must contribute to the understanding of pathophysiology in pulmonary diseases in conjunction with image diagnosis.

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