Pulmonary Function Tests

Measuring the Capacity for Life

Esmeralda E. Morales, MD
September 21, 2004
 Objectives
• Review basic pulmonary anatomy and
physiology.
• Understand the reasons pulmonary function
tests (PFTs) are performed.
• Understand the technique and basic
interpretation of spirometry.
• Know the difference between obstructive
and restrictive lung disease.
• Know how PFTs are clinically applied.
Before you can proceed, you need
to know a little about the lungs…
 What do the lungs do?
• Primary function is gas exchange
• Let oxygen move in
• Let carbon dioxide move out
 How do the lungs do this?
• First, air has to move to the region where
gas exchange occurs.

• For this, you need a normal ribcage and

respiratory muscles that work properly
(among other things).
Conducting Airways
• Air travels via laminar
flow through the
conducting airways
comprised of the
following: trachea, lobar
bronchi, segmental
bronchi, subsegmental
bronchi, small bronchi,
bronchioles, and terminal
bronchioles.
How do the lungs do this? (cont)
• The airways then branch further to
become transitional/respiratory
bronchioles.
• The transitional/respiratory zones are
made up of respiratory bronchioles,
alveolar ducts, and alveoli.
How do the lungs do this? (cont)
• Gas exchange takes place in the acinus.
• This is defined as an anatomical unit of the
lung made of structures supplied by a
terminal bronchiole.
From Netter
Atlas of
Human
Anatomy,
1989
How does gas exchange occur?
• Numerous capillaries are wrapped around
alveoli.
• Gas diffuses across this alveolar-capillary
barrier.
• This barrier is as thin as 0.3 μm in some
places and has a surface area of 50-100
square meters!
Gas Exchange

From Netter
Atlas of
Human
Anatomy,
1989
 What exactly are PFTs?
• The term encompasses a wide variety of objective
methods to assess lung function. (Remember that the
primary function is gas exchange).

• Examples include:
– Spirometry
– Lung volumes by helium dilution or body plethysmography
– Blood gases
– Exercise tests
– Diffusing capacity
– Bronchial challenge testing
– Pulse oximetry
 Why do I care about PFTs?
• Add to diagnosis of disease (pulmonary
and cardiac)
• May help guide management of a disease
process
• Can help monitor progression of disease
and effectiveness of treatment
• Aid in pre-operative assessment of certain
patients
 Yes, PFTs are really wonderful but…
• They do not act alone.
• They act only to support or exclude a
diagnosis.
• A combination of a thorough history and
physical exam, as well as supporting
laboratory data and imaging will help
establish a diagnosis.
 Where would I perform PFTs?
• At home--peak expiratory flow meter/pulse
ox
• Doctor’s office
• Formal PFT laboratory
 When would I order PFTs?
• INDICATIONS FOR SPIROMETRY • Monitoring
• Diagnostic • To assess therapeutic interventions
• To evaluate symptoms, signs, or abnormal • -bronchodilator therapy
laboratory tests
• • -Steroid treatment for asthma, interstitial lung
-Symptoms: dyspnea, wheezing, orthopnea,
cough, phlegm production, disease, etc.
• chest pain • -Management of congestive heart failure
• -Signs: diminished breath sounds, overinflation, • -Other (antibiotics in cystic fibrosis, etc.)
expiratory slowing, • To describe the course of diseases affecting lung
• cyanosis, chest deformity, unexplained crackles function
• -Abnormal laboratory tests: hypoxemia, • -Pulmonary diseases
hypercapnia, polycythemia, • Obstructive airways diseases
• abnormal chest radiographs • Interstitial lung diseases
• To measure the effect of disease on pulmonary • -Cardiac diseases
function • Congestive heart failure
• To screen individuals at risk of having pulmonary • -Neuromuscular diseases
diseases • Guillain-Barre Syndrome
• -Smokers • To monitor persons in occupations with exposure
• -Individuals in occupations with exposures to to injurious agents
injurious substances • To monitor for adverse reactions to drugs with
• -Some routine physical examinations known pulmonary toxicity
• To assess preoperative risk
• To assess prognosis (lung transplant, etc.) (From ATS, 1994)
• To assess health status before enrollment in
strenuous physical activity
• programs
 When would I order PFTs
(cont)?
• Disability/Impairment Evaluations
• To assess patients as part of a rehabilitation program
• -Medical
• -Industrial
• -Vocational
• To assess risks as part of an insurance evaluation
• To assess individuals for legal reasons
• -Social Security or other government compensation programs
• -Personal injury lawsuits
• -Others
• Public Health
• Epidemiologic surveys
• -Comparison of health status of populations living in different
• environments
• -Validation of subjective complaints in occupational/environmental
• settings
• Derivation of reference equations

(From ATS, 1994)

 Spirometry
• “Spirometry is a medical test that measures the
volume of air an individual inhales or exhales
as a function of time. (ATS, 1994)”
 A Brief Aside on History
• John Hutchinson (1811-1861)—inventor of the
spirometer and originator of the term vital
capacity (VC).
• Original spirometer consisted of a calibrated bell
turned upside down in water.
• Observed that VC was directly related to height
and inversely related to age.
• Observations based on living and deceased
subjects.
 A Brief Aside on History
• Hutchinson thought it could apply to life
insurance predictors.
• Not really used much during his time.
• Hutchinson moved to Australia and did not
pursue any other work on spirometry.
• Eventually ended up in Fiji and died (possibly of
murder.)
Silhouette of Hutchinson Performing
Spirometry

From
Chest,
2002
Lung Volumes and Capacities
• 4 volumes: inspiratory
reserve volume, tidal
volume, expiratory
reserve volume, and
residual volume
• 2 or more volumes
comprise a capacity.
• 4 capacites: vital
capacity, inspiratory
capacity, functional
residual capacity, and
total lung capacity
 Lung Volumes
• Tidal Volume (TV): volume of
air inhaled or exhaled with
each breath during quiet
breathing
• Inspiratory Reserve Volume
(IRV): maximum volume of air
inhaled from the end-
inspiratory tidal position
• Expiratory Reserve Volume
(ERV): maximum volume of
air that can be exhaled from
resting end-expiratory tidal
position
 Lung Volumes

• Residual Volume
(RV):
– Volume of air
remaining in lungs
after maximium
exhalation
– Indirectly measured
(FRC-ERV) not by
spirometry
 Lung Capacities
• Total Lung Capacity (TLC):
Sum of all volume
compartments or volume of air
in lungs after maximum
inspiration
• Vital Capacity (VC): TLC minus
RV or maximum volume of air
exhaled from maximal
inspiratory level
• Inspiratory Capacity (IC): Sum
of IRV and TV or the maximum
volume of air that can be
inhaled from the end-expiratory
tidal position
 Lung Capacities (cont.)
• Functional Residual
Capacity (FRC):
– Sum of RV and ERV or the
volume of air in the lungs at
end-expiratory tidal position
– Measured with multiple-
breath closed-circuit helium
dilution, multiple-breath
open-circuit nitrogen
washout, or body
plethysmography (not by
spirometry)
 What information does a spirometer
yield?
• A spirometer can be used to measure the
following:
– FVC and its derivatives (such as FEV1, FEF 25-75%)
– Forced inspiratory vital capacity (FIVC)
– Peak expiratory flow rate
– Maximum voluntary ventilation (MVV)
– Slow VC
– IC, IRV, and ERV
– Pre and post bronchodilator studies
 Forced Expiratory Vital Capacity
• The volume exhaled after a subject inhales
maximally then exhales as fast and hard as
possible.
• Approximates vital capacity during slow
expiration, except may be lower (than true VC)
patients with obstructive disease

How is this done?

 Performance of FVC maneuver
• Check spirometer calibration.
• Explain test.
• Prepare patient.
– Ask about smoking, recent illness, medication
use, etc.
(adapted from ATS, 1994)
 Performance of FVC maneuver
(continued)
• Give instructions and demonstrate:
– Show nose clip and mouthpiece.
– Demonstrate position of head with chin
slightly elevated and neck somewhat
extended.
– Inhale as much as possible, put mouthpiece
in mouth (open circuit), exhale as hard and
fast as possible.
– Give simple instructions.
(adapted from ATS, 1994)
 Performance of FVC maneuver
(continued)
• Patient performs the maneuver
– Patient assumes the position
– Puts nose clip on
– Inhales maximally
– Puts mouthpiece on mouth and closes lips around
mouthpiece (open circuit)
– Exhales as hard and fast and long as possible
– Repeat instructions if necessary –be an effective
coach
– Repeat minimum of three times (check for
reproducibility.)
(adapted from ATS, 1994)
 Special Considerations in Pediatric
Patients
• Ability to perform spirometry dependent on
developmental age of child, personality,
and interest of the child.
• Patients need a calm, relaxed environment
and good coaching. Patience is key.
• Even with the best of environments and
coaching, a child may not be able to
perform spirometry. (And that is OK.)
Flow-Volume Curves and Spirograms
• Two ways to record results of FVC maneuver:

– Flow-volume curve---flow meter measures

flow rate in L/s upon exhalation; flow plotted
as function of volume

– Classic spirogram---volume as a function of

time
Normal Flow-Volume Curve and
Spirogram
 Spirometry Interpretation: So what
constitutes normal?
• Normal values vary and depend on:
– Height
– Age
– Gender
– Ethnicity
Acceptable and Unacceptable
Spirograms (from ATS, 1994)
 Measurements Obtained from the
FVC Curve
• FEV1---the volume exhaled during the first second of the
FVC maneuver

• FEF 25-75%---the mean expiratory flow during the

middle half of the FVC maneuver; reflects flow through
the small (<2 mm in diameter) airways

• FEV1/FVC---the ratio of FEV1 to FVC X 100 (expressed

as a percent); an important value because a reduction of
this ratio from expected values is specific for obstructive
rather than restrictive diseases
Spirometry Interpretation: Obstructive
vs. Restrictive Defect
• Obstructive Disorders • Restrictive Disorders
– Characterized by a – Characterized by reduced
limitation of expiratory lung volumes/decreased
airflow so that airways lung compliance
cannot empty as rapidly Examples:
compared to normal (such – Interstitial Fibrosis
as through narrowed
airways from – Scoliosis
bronchospasm, – Obesity
inflammation, etc.) – Lung Resection
Examples: – Neuromuscular diseases
– Asthma – Cystic Fibrosis
– Emphysema
– Cystic Fibrosis
Normal vs. Obstructive vs.
Restrictive

(Hyatt,
2003)
Spirometry Interpretation: Obstructive
vs. Restrictive Defect
• Obstructive Disorders • Restrictive Disorders
– FVC nl or↓ – FVC ↓
– FEV1 ↓ – FEV1 ↓
– FEF25-75% ↓ – FEF 25-75% nl to ↓
– FEV1/FVC ↓ – FEV1/FVC nl to ↑
– TLC nl or ↑ – TLC ↓
 Spirometry Interpretation: What do
the numbers mean?
• FVC FEV1
• Interpretation of % Interpretation of %
predicted: predicted:
– 80-120% Normal – >75% Normal
– 70-79% Mild reduction – 60%-75% Mild obstruction
– 50%-69% Moderate – 50-59% Moderate
reduction obstruction
– <50% Severe reduction – <49% Severe obstruction
• <25 y.o. add 5% and >60
y.o. subtract 5
Spirometry Interpretation: What do
the numbers mean?
• FEF 25-75% • FEV1/FVC
• Interpretation of % • Interpretation of
predicted: absolute value:
– >79% Normal – 80 or higher
– 60-79% Mild Normal
obstruction – 79 or lower
– 40-59% Moderate Abnormal
obstruction
– <40% Severe
obstruction
 What about lung volumes and
obstructive and restrictive disease?

(From Ruppel,
2003)
 Maximal Inspiratory Flow
• Do FVC maneuver and then inhale as
rapidly and as much as able.
• This makes an inspiratory curve.
• The expiratory and inspiratory flow volume
curves put together make a flow volume
loop.
Flow-Volume Loops

(Rudolph and
Rudolph, 2003)
How is a flow-volume loop helpful?
• Helpful in evaluation of air flow limitation on inspiration
and expiration

• In addition to obstructive and restrictive patterns, flow-

volume loops can show provide information on upper
airway obstruction:
– Fixed obstruction: constant airflow limitation on inspiration and
expiration—such as in tumor, tracheal stenosis
– Variable extrathoracic obstruction: limitation of inspiratory flow,
flattened inspiratory loop—such as in vocal cord dysfunction
– Variable intrathoracic obstruction: flattening of expiratory limb; as
in malignancy or tracheomalacia
 Spirometry Pre and Post
Bronchodilator
• Obtain a flow-volume loop.
• Administer a bronchodilator.
• Obtain the flow-volume loop again a minimum of
15 minutes after administration of the
bronchodilator.
• Calculate percent change (FEV1 most
commonly used---so % change FEV 1= [(FEV1
Post-FEV1 Pre)/FEV1 Pre] X 100).
• Reversibility is with 12% or greater change.
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 References
• American Thoracic Society: Standardization of
Spirometry: 1994 update. American Journal of
Respiratory and Critical Care Medicine. 152:1107-1136,
1995.
• Blonshine, SB: Pediatric Pulmonary Function Testing.
Respiratory Care Clinics of North America. 6(1): 27-40.
• Hyatt, RE: Scanlon, PD, Nakamura, M. Interpretation of
Pulmonary Function Tests: A Practical Guide. 2003,
Lippincott Williams & Wilkins.
 References
• Petty, TL: John Hutchinson’s Mysterious Machine
Revisited. Chest 121:219S-223S
• Ruppel, GL: Manual of Pulmonary Function Testing.
2003, Mosby.
• Rudolph, CD and Rudolph, AM: Rudolph’s Pediatrics 21st
Ed. 2003, McGraw-Hill.
• Wanger, J: Pulmonary Function Testing: A Practical
Approach 2nd Ed. 1996, Williams & Wilkins.
• West, JB: Pulmonary Pathophysiology: The Essentials
6th Ed. 2003, Lippincott Williams & Wilkins.
• West, JB: Respiratory Physiology: The Essentials 6th Ed.
2000, Lippincott Williams & Wilkins.