Pulmonary Function Testing

ALVIN C. GUEVARRA, RTRP

 Objectives
▪ Briefly review pulmonary anatomy and
physiology
▪ Identify the components of PFTs
▪ Describe the indications
▪ Develop a stepwise approach to interpretation
▪ Recognize common patterns
▪ Apply this information to patient care
 Anatomy
• Lungs comprised of
– Airways
– Alveoli
 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
 The Alveoli
• Approximately 300
million alveoli
• 1/3 mm diameter
• Total surface area if
they were complete
spheres 85 sq.
meters (size of a
tennis court)

Murray & Nadel: Textbook of Respiratory

Medicine, 3rd ed., Copyright © 2000 W. B.
Saunders Company
 Mechanics of Breathing
• Inspiration
– Active process
• Expiration
– Quiet breathing: passive
– Can become active
Lung Volumes

• 4 Volumes
• 4 Capacities
IRV – Sum of 2 or
IC
more lung
VC
TV volumes
TLC
ERV
FRC
RV RV
Tidal Volume (TV)
• Volume of air
inspired and
expired during
IRV normal quiet
IC
VC
breathing
TV
TLC
ERV
FRC
RV RV
Inspiratory Reserve Volume (IRV)

• The maximum
amount of air
that can be
IRV inhaled after a
IC
VC
normal tidal
TV volume
TLC
inspiration
ERV
FRC
RV RV
Expiratory Reserve Volume (ERV)

• Maximum
amount of air
that can be
IRV exhaled from
IC
VC
the resting
TV expiratory level
TLC
ERV
FRC
RV RV
Residual Volume (RV)
• Volume of air
remaining in the
lungs at the end
IRV of maximum
IC
VC
expiration
TV
TLC
ERV
FRC
RV RV
Vital Capacity (VC)
• Volume of air that
can be exhaled
from the lungs
IRV after a maximum
IC inspiration
VC
TV • FVC: when VC
TLC
exhaled forcefully
ERV
• SVC: when VC is
FRC
exhaled slowly
RV RV
• VC = IRV + TV +
ERV
Inspiratory Capacity (IC)
• Maximum
amount of air
that can be
IRV inhaled from the
IC
VC
end of a tidal
TV volume
TLC
ERV • IC = IRV + TV
FRC
RV RV
Functional Residual Capacity (FRC)

• Volume of air
remaining in the
lungs at the end of
IRV a TV expiration
IC
VC • The elastic force of
TV the chest wall is
TLC
ERV exactly balanced by
FRC the elastic force of
RV RV the lungs
• FRC = ERV + RV
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
RV RV
 Pulmonary Function Testing

Which of the following is used to follow disease severity in

COPD patients?

a. Total lung capacity (TLC)

b. Degree of responsiveness to bronchodilators
c. Forced vital capacity (FVC)
d. Forced expiratory volume in 1 second
e. Diffusing capacity (DLCO)
 Pulmonary Function Testing

A 36yo WF, non-smoker, presents to your office for follow-up of

‘recurrent bronchitis.’ You suspect asthma and decide to
order spirometry. Which of the following would you
include in your prescription for testing?

a. Diffusing Capacity (DLCO)

b. If no obstruction present, add trial of bronchodilator
c. If no obstruction present, perform methacholine challenge
d. Flow volume loop
e. b and c
 Pulmonary Function Testing

A 68yo HM is admitted to the ICU with acute respiratory

distress. A CXR obtained in the ED demonstrates
bilateral pulmonary infiltrates, and his DLCO is
elevated. What is the most likely diagnosis?

a. Pulmonary edema
b. Aspiration pneumonitis
c. Pulmonary emboli
d. Alveolar hemorrhage
e. Interstitial lung disease
 The Purpose

Provide quantifiable, reproducible

measurement of lung function
 Description
▪ Spirometry
▪ Flow Volume Loop
▪ Bronchodilator response
▪ Lung volumes
▪ Diffusion capacity (DLCO)
▪ Bronchoprovocation testing
▪ Maximum respiratory pressures
▪ Simple and complex cardiopulmonary exercise
testing
 Indications — Diagnosis

▪ Evaluation of signs and symptoms

- SOB, exertional dyspnea, chronic cough
▪ Screening at-risk populations
▪ Evaluation of occupational symptoms
▪ Monitoring pulmonary drug toxicity
▪ Abnormal study
- CXR, EKG, ABG, hemoglobin
▪ Preoperative assessment
 Indications — Diagnosis

▪ Evaluation of signs and symptoms

- SOB, exertional dyspnea, chronic cough
▪ Screening at-risk populations
Smokers > 45yo
▪ Evaluation of occupational symptoms
(former & current)
▪ Monitoring pulmonary drug toxicity
▪ Abnormal study
- CXR, EKG, ABG, hemoglobin
▪ Preoperative assessment
 Indications — Diagnosis

▪ Evaluation of signs and symptoms

- SOB, exertional dyspnea, chronic cough
▪ Screening at-risk populations
▪ Evaluation of occupational symptoms
▪ Monitoring pulmonary drug toxicity
▪ Abnormal study
- CXR, EKG, ABG, hemoglobin
▪ Preoperative assessment
 Indications — Prognostic

■ Assess severity

■ Follow response to therapy

■ Determine further treatment goals

■ Referral for surgery

■ Disability
Factors That Affect Lung Volumes
• Age
• Sex
• Height
• Weight
• Race
• Disease
 Spirometry

▪ Simple, office-based
▪ Measures flow, volumes
▪ Volume vs. Time
▪ Can determine:
- Forced expiratory volume in one second (FEV1)
- Forced vital capacity (FVC)
- FEV1/FVC
- Forced expiratory flow 25%-75% (FEF25-75)
Lung Factors Affecting Spirometry

• Mechanical properties
• Resistive elements
 Mechanical Properties
• Compliance
– Describes the stiffness of the lungs
– Change in volume over the change in
pressure
• Elastic recoil
– The tendency of the lung to return to it’s
resting state
– A lung that is fully stretched has more elastic
recoil and thus larger maximal flows
 Resistive Properties
• Determined by airway caliber
• Affected by
– Lung volume
– Bronchial smooth muscles
– Airway collapsibility
 Technique
• Have patient seated comfortably
• Closed-circuit technique
– Place nose clip on
– Have patient breathe on mouthpiece
– Have patient take a deep breath as fast as
possible
– Blow out as hard as they can until you tell
them to stop
Terminology

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

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

FEV1 FVC
Terminology

• Forced expiratory flow 25-

75% (FEF25-75)
– Mean forced expiratory flow
during middle half of FVC
– Measured in L/sec
– May reflect effort
independent expiration and
the status of the small
airways
– Highly variable
– Depends heavily on FVC
 FEF25-75
• Interpretation of % predicted:
– >60% Normal
– 40-60% Mild obstruction
– 20-40% Moderate obstruction
– <10% Severe obstruction
 Acceptability Criteria
• Good start of test
• No coughing
• No variable flow
• No early termination
• Reproducibility
Spirometry
 Categories of Disease

• Obstructive
• Restrictive
• Mixed
Normal Spirometry
Obstructive Pattern

▪ Characterized by a
limitation of
expiratory airflow
▪ Increased or
Normal: TLC
▪ Decreased: FEF25-
75
Obstructive Pattern

▪ Slow rise in
upstroke
▪ May not reach
plateau
 Obstructive Pattern

■ Decreased FEV1
■ Decreased FVC

■ Decreased FEV1/FVC
- <70% predicted

■ FEV1 used to follow severity in COPD

 Obstructive Lung Disease —
Differential Diagnosis

▪ Asthma
▪ COPD
- chronic bronchitis
- emphysema
▪ Bronchiectasis
▪ Bronchiolitis
▪ Upper airway obstruction
Restrictive Lung Disease

▪ Characterized by diminished
lung volume due to:
▪ change in alteration in lung
parenchyma (interstitial
lung disease)
▪ disease of pleura, chest
wall (e.g. scoliosis), or
neuromuscular apparatus
(e.g. muscular dystrophy)
Restrictive Disease

▪ Rapid upstroke
as in normal
spirometry
▪ Plateau volume
is low
 Restrictive Pattern

▪ Decreased FEV1

▪ Decreased FVC

▪ FEV1/FVC normal or increased

 Restrictive Lung Disease —
Differential Diagnosis

▪ Pleural

▪ Parenchymal

▪ Chest wall

▪ Neuromuscular
Spirometry Patterns
 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

 Flow Volume Loop

▪ “Spirogram”

▪ Measures forced inspiratory and expiratory

flow rate

▪ Augments spirometry results

▪ Indications: evaluation of upper airway

obstruction (stridor, unexplained dyspnea)
Flow Volume Loop
 Upper Airway Obstruction
▪ Variable intrathoracic obstruction
▪ The maximal airflow limitation occurs in
expiration
▪ Variable extrathoracic obstruction
▪ Airflow limitation is during inspiration
▪ Fixed obstruction
▪ A persistent airflow limitation through the
airways, especially when exhaling
Upper Airway Obstruction

▪ Characterized by
a truncated
inspiratory or
expiratory loop
Upper Airway Obstruction
Changes in Lung Volumes in Various
Disease States

Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
 Lung Volumes

▪ Measurement:
- helium
- nitrogen washout
- body plethysmography

▪ Indications:
- Diagnose restrictive component
- Differentiate chronic bronchitis from
emphysema
Measuring Lung Volumes and
Capacities
3 Methods on Measuring Lung Volumes and
Capacities
1. Helium Dilution
2. Nitrogen Washout
3. Body Plethysmograph
 Helium Dilution
▪ Equilibration of Helium can occur between the
spirometer and the lungs.
▪ Uses a closed, rebreathing circuit
▪ Healthy patients: equilibration occurs in 2-5
minutes
▪ Patients with obstructive lung disease:
equilibration occurs at least 20 minutes
Helium Dilution
Helium Dilution
 Nitrogen Washout
▪ Based on the assumptions that the
nitrogen concentration in the lungs is 78%
and in equilibrium with the atmosphere,
that the patient inhales 100% O2, and that
the O2 replaces all of the nitrogen in the
lungs.
▪ Uses a nonrebreathing or open circuit
Nitrogen Washout
 Lung Volumes – Patterns

▪ Obstructive
- TLC > 120% predicted
- RV > 120% predicted

▪ Restrictive
- TLC < 80% predicted
- RV < 80% predicted
 Plethysmography
▪ Uses Boyle’s law
▪ Uses measurements of volume changes
(ΔV) and pressure changes (ΔP) to
determine lung volume, assuming
temperature is constant
▪ Whole-Body plethysmograph consists of a
sealed chamber in which the patient sits
 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
 Diffusing Capacity

▪ Decreased DLCO ▪ Increased DLCO

(<80% predicted) (>120-140% predicted)

▪ Obstructive lung disease ▪ Asthma (or normal)

▪ Parenchymal disease ▪ Pulmonary hemorrhage

▪ Pulmonary vascular ▪ Polycythemia

disease
▪ Left to right shunt
▪ Anemia
 DLCO — Indications

▪ Differentiate asthma from emphysema

▪ Evaluation and severity of restrictive lung

disease

▪ Early stages of pulmonary hypertension

▪ Expensive!
 Case 1

CC/HPI: A 36yo WM, nonsmoker, presents to your

clinic with c/o episodic cough for 6mo. Also
reports occasional wheezing and dyspnea with
exertion during softball practice.

Exam: Heart RRR, no murmurs; Lungs CTAB, no

labored breathing

Based on your exam and a thorough review of

systems, you suspect asthma and decide to
order spirometry for further evaluation.
Continued…

PFTs: FEV1 86% predicted

FEV1/FVC 82% predicted

Flow Volume Loop: normal inspiratory and

expiratory pattern

You still suspect asthma. What is your next

step in the workup of this patient?
 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

Continued…

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

▪ What is the clinical question?

▪ What is “normal”?

▪ Did the test meet American Thoracic Society

(ATS) criteria?

▪ Don’t forget (or ignore) the flow volume loop!

Obstructive Pattern — Evaluation

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

▪ FV Loop “scooped”, “dog leg”, “steeple”

▪ Lung Volumes
▪ TLC, RV: increased

▪ Bronchodilator responsiveness
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

 PFT Patterns

▪ Emphysema ▪ Chronic Bronchitis

▪ FEV1/FVC <70% ▪ FEV1/FVC <70%

▪ “Scooped” FV curve ▪ “Scooped” FV curve

▪ TLC increased ▪ TLC normal

▪ Increased compliance ▪ Normal compliance

▪ DLCO decreased ▪ DLCO usually normal

 PFT Patterns

▪ Asthma

▪ FEV1/FVC normal or decreased

▪ DLCO normal or increased

But PFTs may be normal → bronchoprovocation

 Interpretation

86
 Pulmonary Function Testing
Jennifer Hale, M.D.

Which of the following is used to follow disease severity in

COPD patients?

a. Total lung capacity (TLC)

b. Degree of responsiveness to bronchodilators
c. Forced vital capacity (FVC)
d. Forced expiratory volume in 1 second
e. Diffusing capacity (DLCO)
 Pulmonary Function Testing
Jennifer Hale, M.D.

Which of the following is used to follow disease severity in

COPD patients?

a. Total lung capacity (TLC)

b. Degree of responsiveness to bronchodilators
c. Forced vital capacity (FVC)
d. Forced expiratory volume in 1 second
e. Diffusing capacity (DLCO)
 Pulmonary Function Testing
Jennifer Hale, M.D.

A 36yo WF, non-smoker, presents to your office for follow-up of

‘recurrent bronchitis.’ You suspect asthma and decide to
order spirometry. Which of the following would you
include in your prescription for testing?

a. Diffusing Capacity (DLCO)

b. If no obstruction present, add trial of bronchodilator
c. If no obstruction present, perform methacholine challenge
d. Flow volume loop
e. b and c
 Pulmonary Function Testing
Jennifer Hale, M.D.

A 36yo WF, non-smoker, presents to your office for follow-up of

‘recurrent bronchitis.’ You suspect asthma and decide to
order spirometry. Which of the following would you
include in your prescription for testing?

a. Diffusing Capacity (DLCO)

b. If no obstruction present, add trial of bronchodilator
c. If no obstruction present, perform methacholine challenge
d. Flow volume loop
e. b and c
 Pulmonary Function Testing
Jennifer Hale, M.D.

A 68yo HM is admitted to the ICU with acute respiratory

distress. A CXR obtained in the ED demonstrates
bilateral pulmonary infiltrates, and his DLCO is
elevated. What is the most likely diagnosis?

a. Pulmonary edema
b. Aspiration pneumonitis
c. Pulmonary emboli
d. Alveolar hemorrhage
e. Interstitial lung disease
 Pulmonary Function Testing
Jennifer Hale, M.D.

A 68yo HM is admitted to the ICU with acute respiratory

distress. A CXR obtained in the ED demonstrates
bilateral pulmonary infiltrates, and his DLCO is
elevated. What is the most likely diagnosis?

a. Pulmonary edema
b. Aspiration pneumonitis
c. Pulmonary emboli
d. Alveolar hemorrhage
e. Interstitial lung disease
 THINGS TO REMEMBER:
• There should be three readings, of which
the best two are within 150 mL or 5% of
each other and best.
• Ideally, calibration should be performed
with a 3-liter syringe which will allow
validation of spirometer accuracy.
• Short-acting bronchodilators should be
withheld for the previous 6 hours, long-
acting bronchodilators for 12 hours, and
sustained release theophylline for 24
hours.
• FEV1/FVC should be measured before
and 15-20 minutes after bronchodilator is
given.
Case #1
Case #2
Case #3
Case #4
Case #5
Questions?
 References
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2003.
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Physician. 2004 Mar 1;69(5):1107-14.
4. Chesnutt MS, Prendergast TJ. Current Medical Diagnosis and Treatment.
New York: Appleton and Lange, 2006.
5. Enright PL: Diffusing capacity for carbon monoxide. UpToDate, 2007.
6. Enright PL: Overview of pulmonary function testing in adults. UpToDate,
2007.
7. Irvin CG: Bronchoprovocation testing. UpToDate, 2006.
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Wilkins, 2000.