PULMONARY FUNCTION TESTS

MODERATOR- DR DHEERAJ KAPOOR

PRESENTOR- DR CHAKSHU JYANNI
 PULMONARY FUNCTION TEST
Battery of tests/ maneuvers that may be performed using
standardized equipment to measure lung function
Includes wide variety of objective tests to identify and
quantify lung function

Only supports or excludes a diagnosis

Evaluate one or more major aspects of the respiratory

system:
1. Respiratory mechanics
2. Lung parenchyma function
3. Cardiopulmonary interaction
 Indications
1. Clinical evaluation of patients with
symptoms/signs/investigations that suggest pulmonary
dysfunction.
2. Functional nature of disease
3. Severity & progression of known disease
4. Assess response to treatment
5. Risk stratification of patients planned for pulmonary
resection/ any other surgery with concurrent pulmonary
pathology.
6. Screening of patients at risk
7. Assess lung transplant rejection
 Limitations:

1. Variability in normal predictive value

2. Accuracy- Technician’s skill & patient’s understanding
& cooperation
3. Must be combined with proper history, physical
examination, ancillary diagnostic tests to confirm
diagnosis
 American College of Physicians Guidelines

ACP modified this guidelines to decrease the unnecessary

ordering of preoperative spirometry
 Lung resection
 H/o smoking, dyspnoea
 Cardiac surgery
 Upper abdominal surgery
 Lower abdominal surgery
 Uncharacterized pulmonary disease(defined as history of
pulmonary disease or symptoms and no PFT in last 60 days)
PFT CATEGORIES

1) Mechanical And Ventilatory Functions Of Lung / Chest

Wall
2) Gas- Exchange Tests
3) Cardiopulmonary Interaction
4) CPET(Cardiopulmonary Exercise Testing)
 PFT CATEGORIES

Mechanical and CARDIOPULMON CPET(cardiopulmo

GAS- EXCHANGE
ventilatory functions ARY nary exercise
TESTS:
of lung/ chest wall INTERACTION: testing)
• Bedside PFT • Alveolar-arterial po2 Qualitative test -
• Static Lung Vol and gradient History ,
Capacities- VC • Diffusion capacity examination and
IRV, ERV, RV, FRC. • Gas distribution ABG
• Dynamic Lung Vol – tests- • Quantitative tests
FVC, FEV1, FEF • Single breath N2 • 6 min walk test
25-75%, PEFR, test. • Stair climbing
MVV, Respiratory • Multiple Breath test
Muscle Strength • Shuttle walk
N2 test
• Helium dilution
method
• Radio Xe
scinitigram.
BED SIDE PFTS:
1. Sabrasez breath holding test
2. Single breath count
3. Schneider’s match blowing test
4. Cough test
5. Forced expiratory time
6. Wright peak flowmeter
7. Microspirometers
8. Debono whistle blowing test
9. Wright respirometer
[Link] side pulse oximetry
Lung Volume And Capacities
 1) SABRASEZ BREATH HOLDING TEST :
Ask the patient to take a full but not too deep breath & hold it as long as
possible.
• >25 SEC-NORMAL Cardiopulmonary Reserve (CPR)
• 15-25 SEC- LIMITED CPR
• <15 SEC- VERY POOR CPR

25- 30 SEC - 3500 ml VC

20-25 SEC - 3000 ml VC
15-20 SEC - 2500 ml VC
10-15 SEC - 2000 ml VC
5-10 SEC - 1500 ml VC
 2) SCHNEIDER’S MATCH BLOWING TEST:
 Measures Maximum Breathing Capacity
 Ask to blow a match stick from a distance of 6” (15 cm) with-
• Mouth wide open
• Chin rested/supported
• No purse liping
• No head movement
• No air movement in the room
• Mouth and match at the same level
 SCHNEIDER’S MATCH BLOWING TEST:

• Can not blow out a match Modified match test:

FEV1 < 1.6L
DISTANCE (max. breathing capacity)
• Able to blow out a match
FEV1 > 1.6L • 9” >150 L/MIN
• 6” >60 L/MIN
• 3” > 40 L/MIN
3) COUGH TEST: Deep breath followed by cough
• Ability to cough/ Strength/ Effectiveness of action of respiratory muscles

Inadequate cough if:

• FVC <20 ml/kg
• FEV1 < 15 ml/kg
• PEFR(peak expiratory flow rate) < 200 lit/min.

• VC ~ 3 times TV for effective cough

• A wet productive cough / self propagated paroxysms of coughing may

indicate some underlying pathology – susceptibility for pulmonary
complication.
4) FORCED EXPIRATORY TIME:
• After deep breath, exhale maximally and forcefully & keep
stethoscope over trachea & listen
• Normal FET – 3-5 sec
• OBS. Lung Disease > 6 sec
• RES. Lung Disease < 3 sec

5) SINGLE BREATH COUNT:

• After deep breath, hold it and start counting till the next breath
• Normal- 30-40 count
• Indicates vital capacity
6) WRIGHT PEAK FLOW METER:
Measures peak expiratory flow rate
Male: 450-700 L/min.
Female: 350-500 L/min.
7) MICROSPIROMETER

Measure FEV1 and FVC

 8) DE-BONO WHISTLE BLOWING TEST

Measures PEFR
• Patient blows down a wide bore tube
at the end of which is a whistle, on
the side is a hole with adjustable
knob
• As subject blows → whistle blows,
the leak hole is gradually increased
till the intensity of whistle
disappears
• At the last position at which the
whistle can be blown , the PEFR can
be read off the scale
 9) WRIGHT RESPIROMETER

Measures TV & MV
• Instrument- compact, light and portable
• Can be connected to endotracheal tube
or face mask
• MV- instrument record for 1 min. And
read directly
• TV-calculated by dividing MV after
counting Respiratory Rate.
• Disadvantage: under-reads at low flow
rates and over-reads at high flow rates
SPIROMETRY
• Cornerstone of all the pulmonary function tests
• Spirometry is a medical test that measures the
volume of air an individual inhales or exhales as a
function of time.
• Assess mechanical function of lungs
• Measures amount and rapidity of air that can be
exhaled or inhaled by the person
• Primary signal measured may be volume or flow
• CAN’T MEASURE – FRC, RV, TLC
Spirometry

Types of spirometer
• Bellows or rolling seal :
large and used in lung
function labs
• Electronic desktype :
Portable ,quick and easy
to use .Real time visual
display
• Hand-held spirometers

Handheld Spirometer
 Indication of
Spirometry
1) Diagnostic- 2) Monitoring-
• To evaluate symptoms signs or abnormal • To assess therapeutic
laboratory tests. intervention
• To measure the effect of disease on • To describe the course of
pulmonary function. disease that affect lung
• To screen individual at risk of having function
pulmonary disease. • To monitor people
exposed to injurious
• To assess pre-operative risk
agents
• To assess prognosis • To monitor for adverse
• To assess health status before beginning reactions to drug with
strenuous physical activity known pulmonary toxicity
 Indication of Spirometry
3) Disability/Impairment 4) Public Health
evaluations-
• To assess patient as a part • Epidemiological
of rehabilitation Surveys.
programme. • Derivations of
• To assess risk as a part of reference equations
insurance evaluation • Clinical research
• To assess individual for
legal reasons.
WHAT CONSTITUTES NORMAL
SPIROMETRY?
Normal values vary and depend on:
1. Height – Directly proportional
2. Age – Inversely proportional
3. Gender
4. Ethnicity
TYPES OF SPIROMETRY

Static Spirometry :
Anatomical measurement of lung
Measures TV , IRV , ERV , IC , EC and slow vital
capacity .
Dynamic Spirometry :
Measures rate of ventilation .
Measures Forced vital capacity , forced expiratory
volume , peak expiratory flow rate , maximal mid –
expiratory flow rate
NORMAL CURVE:
• Graphs obtained from spirometry are known as
spirograms.
• Two types :
• Volume – time curve
• Flow –Volume loops
NORMAL SPIROMETRY CURVES
ACCEPTABILITY CRITERIA

• Satisfactory start- without any hesitation for 1st sec

• Artifacts: No coughing / glottic closure
• No variable flow
• Good start
• Time to PEF is <120 ms
• Satisfactory exhalation -6 sec of exhalation and/or a
plateau in the volume-time curve
• No air leak
COMMON ERRORS: Q and A?
1 SUB MAXIMAL INHALATION
2 SUB-MAXIMAL BLAST
3 COUGH
4 VARIABLE EFFORT
5 GLOTTIC CLOSURE OR BREATH HOLDING
6 LEAK
7 EXTRA BREATH(s)
Measurement of RV, FRC

Methods:
 Nitrogen washout technique
 Helium dilution method
 Body plethysmography
 Nitrogen washout technique

Following Normal expiration

Inspire 100% oxygenation

All nitrogen in lungs washed out

Exhaled volume and the nitrogen

concentration in that volume are
measured.
Helium Dilution technique

Pt breathes in and out from

a reservoir with known
volume of gas containing
trace of helium.
Helium gets diluted by gas
previously present in
lungs.
Helium Dilution technique
• C1×V1 = C2×V2
• C1×V1 = C2×(V1+FRC)
• FRC = ((C1xV1)/C2) - V1

• V2 = total gas volume ( FRC + volume of

spirometer)
• V1 = volume of gas in spirometer
• C1 = initial (known) helium concentration
• C2 = final helium concentration (measured by
the spirometer)
BODY PLETHYSMOGRAPHY
 Based on Boyle’s law.
P x V = Constant
Unknown lung gas vol. = Gas pressure of the box
Known box gas vol. = Gas pressure of lungs
 Patient is placed in a sitting position in a closed body
box with a known volume
 The patient pants with an open glottis against a
closed shutter to produce changes in the box
pressure proportionate to the volume of air in the
chest
BODY PLETHYSMOGRAPHY

 As measurements done at end of expiration, it yields FRC

 Body plethysmography is the gold standard for measurement of
lung volumes, particularly in the setting of significant airflow
obstruction
 Helium dilution and nitrogen washout may underestimate lung
volume in patients with moderate to severe COPD because they do
not access under or nonventilated areas.
DYNAMIC LUNG VOLUMES/FORCED
SPIROMETRY
Forced spirometry
MEASUREMENTS OBTAINED FROM
FVC CURVE:
• FEV1: Volume exhaled during 1st second of FVC
maneuver Decreased in both restrictive & obstructive
lung disorder
CLINICAL RANGE PATIENT GROUP
3-4.5 L Normal adult
1.5-2.5 L Mild to moderate obstruction
<1 L Severe obstruction

• FEF 25-75%: Reduced in obstructive disorder

• FEV1/FVC: Reduction of this ratio from expected value
is more specific for obstructive rather than restrictive
disorders
FVC CURVE
FVC CURVE

IN Obstructive disease
BB Restrictive ds
Obstructive disease
Restrictive disease
Mixed obstructive and restrictive
disease
FORCED MID-EXPIRATORY FLOW 25-
75%
• Max. Flow rate during the mid-
expiratory part of FVC
maneuver.
• Measured in L/sec
• May reflect effort independent
expiration and the status of the
small airways
• Highly variable
• Depends heavily on FVC
• N value – 4.5-5 L/sec or 300
INTERPRETATION
FEV1/FVC:-
FEF25-75%:-
• >75% Normal
• >60% Normal
• 60%-75% Mild
• 40-60% Mild
obstruction
• 50-59% Moderate obstruction
• 20-40% Moderate
obstruction obstruction
• <49% Severe • <10% Severe
obstruction
• obstruction
PEAK EXPIRATORY FLOW RATE

• Maximum flow rate during an FVC maneuver occuring

in initial 0.1 sec
• After a maximal inspiration, the patient expires as
forcefully and quickly as he can and the maximum flow
rate of air is measured
• Gives a crude estimate of lung function, reflecting
larger airway function
• Effort dependent but is highly reproducible
 PEAK EXPIRATORY FLOW RATE
• Measured by peak flow meter

• How much air (L/min) is being

blown out or by spirometry
• In normal adults variation depends
on age and height.
• Normal : 450 - 700 L/min in males
• 300-500 L/min in
females
• Clinical significance - value of
<200L/min- impaired coughing &
hence likelihood of post-op
complication
Maximum Voluntary Ventilation (MVV)
• Also known as Maximum Breathing Capacity
(MBC)
• Measures - speed and efficiency of filling &
emptying of the lungs during increased respiratory
effort
• Maximum volume of air that can be breathed in
and out of the lungs in 1 minute by maximum
voluntary effort
• It reflects peak ventilation in physiological
demands
• Normal : 150 -175 L/min.
• Decreased in obstructive disorders
Maximum Voluntary Ventilation (MVV)
• Patient breaths as
quickly and deeply as
possible for 12 sec and
the measured volume is
extrapolated to1min.
• MVV is markedly
decreased in patients with:
• Emphysema
• Airway obstruction
• Poor respiratory muscle
strength
When trying to determine whether a breathless pt
has obstructive or restrictive pulmonary disease?
• A) it is necessary to make measurements of airway resistance and
lung compliance
• B) PEFR above predicted value indicates restrictive disease
• C) most useful test is forced expiratory spirogram (exhaled vol vs time)
• D) inspiratory wheezing would be expected in obstructive pulm.
disease

C
FEV1:
• A) increases with age until a person stops growing when he/she is
about 18 yrs old
• B) remains at the same level once it has reached its peak value
provided that the person does not smoke or has a resp disease
• C) if its value in litres is reduced but it is normal as a percentage of the
subject’s FVC (>75% FVC), it indicates restrictive lung disease
• D) not greatly affected by the subject’s efforts and technique

C
Best single measurement indicating a resp problem
and which is reproducible and best correlates with
function and prognosis is?

• A) FEV1
• B) FVC
• C) PEFR
• D) MVV

A
 PFT CATEGORIES

Mechanical and CARDIOPULMON CPET(cardiopulmo

GAS- EXCHANGE
ventilatory functions ARY nary exercise
TESTS:
of lung/ chest wall INTERACTION: testing)
• Bedside PFT • Alveolar-arterial po2 Qualitative test -
• Static Lung Vol and gradient History ,
Capacities- VC • Diffusion capacity examination and
IRV, ERV, RV, FRC. • Gas distribution ABG
• Dynamic Lung Vol – tests- • Quantitative tests
FVC, FEV1, FEF • Single breath N2 • 6 min walk test
25-75%, PEFR, test. • Stair climbing
MVV, Respiratory • Multiple Breath test
Muscle Strength • Shuttle walk
N2 test
• Helium dilution
method
• Radio Xe
scinitigram.
Tests for gas exchange fuction
ALVEOLAR-ARTERIAL O2 TENSION
GRADIENT:
 Sensitiveindicator of detecting regional V/Q inequality
 Abnormal high values at room air is seen in
asymptomatic smokers & chronic bronchitis (min.
symptoms)
A-a gradient = PAO2 - PaO2
• PAO2 = alveolar PO2 (calculated from the alveolar
gas equation)
• PaO2 = arterial PO2 (measured in arterial gas)
Alveolar gas equation
DIFFUSING CAPACITY:
• Diffusion capacity of lung estimates the ability of
lung to transfer oxygen from alveolar gas to red cells
• Rate at which gas enters the blood divided by its
driving pressure ( gradient – alveolar and end
capillary tensions)
• Measures how well a gas diffuses across the respiratory
membrane.
• Normal- 20-30 ml/min/mm Hg
• Depends on:
 thickness of alveolar—capillary membrane
 hemoglobin concentration
 cardiac output
SINGLE BREATH TEST USING CO
• Pt inspires a dilute mixture of CO and hold the breath for
10 sec and exhale.
• CO taken up is determined by infrared analysis:
 DLCO = CO (ml/min/mmHg)
PACO – PcCO
• Why CO?
 High affinity for Hb which is approx. 200 times that of
O2 , so does not rapidly build up in plasma
 Under normal condition it has low blood conc.≈ 0
 Therefore, pulm conc.≈0
 Harmless at low concentration
SINGLE BREATH TEST USING CO

• DLCO is low in ILD, but normal in

disorders of pleura, chest and
neuromuscular disorder causing restrictive
lung function.
• Useful for following the course of or
response to therapy in ILD.
FACTORS AFFECTING DLCO

DECREASE(< 80% INCREASE(> 120-140%

predicted) predicted)

Anemia Polycythemia

Carboxyhemoglobin Exercise

Pulmonary embolism

Diffuse pulmonary fibrosis

Pulmonary emphysema
54 yr male persistent changes on cxray. History shows
reduced exercise tolerance for months. Pft was done
which reveals the following. What is the likely diagnosis?
result predicted % predicted
FEV1 2.12 lit 3.08 lit 69%
FVC 2.59 lit 3.81lit 68%
FEV1/FVC 0.82 0.80 103%
TLC 3.05 lit 4.24lit 72%
DLCO 15.57 ml/min/mmhg 22.90lit 68%

a) emphysema
b) Chronic bronchitis
c) Pulmonary fibrosis
C
d) bronchiectasis
60/m, smoker, 6months h/o progressive shortness of
breath and reduced exercise tolerance. Spirometry
as follows:
result predicted % predicted
FEV1 2.68 lit 3.72 lit 72%
FVC 4.12 lit 4.92lit 84%
FEV1/FVC 0.65 0.76 86%

Diagnosis:
a) Asthma
b) COPD B
c) ILD
d) Pulm embolus
What pattern is depicted by following
picture?

A. Obstructive lung ds
B. Restrictive lung ds
C. Fixed upper airway obstruction
D. Variable intrathoracic obstruction

A
46/F, smoker, exertional dyspnea on and off
from her teenage. Spirometry as follows:
Pre brononchodilator % predicted pre Post brononchodilator % predicted

FEV1 2.30 lit 68% 2.74 lit 81%

FVC 3.83 lit 91% 3.98 lit 89%
FEV1/FVC 0.64 85% 0.66 87%

Diagnosis:
a) Asthma
b) Emphysema A
c) Chronic bronchitis FEV1 improved by both more
than 200ml and more than 12%
d) bronchiectasis post bronchodilator therapy
43/F,non smoker, 6months h/o cough and
shortness of breath. Spirometry as follows:
result predicted % predicted
FEV1 2.30 lit 3.32 lit 69%
FVC 2.8 lit 4.12lit 68%
FEV1/FVC 0.82 0.82 100%

Diagnosis:
C
a) Asthma Reduced FVC and Normal
Spirometer Ratio s/o restrictive
b) COPD disease
c) ILD
d) Pulm embolus
48 yr male, 12 months h/o progressive shortness of breath which
was causing him significant distress to the point he was unable to
exercise. Pft was done which reveals the following. What is the likely
diagnosis?
result predicted % predicted
FEV1 1.97 lit 2.90 lit 69%
FVC 2.59 lit 3.81lit 68%
FEV1/FVC 0.76 0.75 101%
TLC 3.75 lit 5.21 lit 72%
DLCO 21.27 ml/min/mmhg 20.84lit 102%

a) Asthma
b) COPD
D
FVC is reduced, normal spirometric ratio: RLD
c) ILD DLCO is normal: no parenchymal issue
d) Myasthenia Gravis Hence chest wall deformity/neurologic/ neuromuscular
C/I for spirometery?
A. Previous icu admission for asthma
B. Being on home oxygen
C. Lung cancer
D. pneumothorax
D
Acutely unwell
Hemoptysis of unknown origin
Pneumothorax
Recent Abd/thoracic/eye surgery
Recent MI
Known aneurysm
Tests for cardiopulmonary reserve
 TESTS FOR CARDIOPULMONARY
RESERVE:
Stair Climbing And 6-minute Walk Test:
This is a simple test that is easy to perform with
minimal equipment.
Performance VO2 Interpretation
max(ml/kg/min)
>5 flight of stairs > 20 Low mortality after
pneumonectomy,
FEV1>2l
>3 flight of stairs Low mortality after
lobectomy, FEV1>1.7l
<2 flight of stairs Correlates with high
mortality
<1 flight of stairs <10

6 min walk test <600 m <15

• Each stair height should be?

Stair height= 20 cm

• 2 flight of stairs corresponding to how many number of stairs?

2 flight of stairs = 44
SHUTTLE WALK TEST:
• The patient walks between cones 10
meters apart with increasing pace
• The subject walks until they cannot make
it from cone to cone between the beeps
• Less than 250m or decrease SaO2 > 4%
signifies high risk
• A shuttle walk of 350m correlates with a
VO2 max of 11ml/kg/min
 Cardiopulmonary Exercise Testing
• Non invasive technique :cycling or
treadmill
• To test ability of subjects physiological
response to cope with metabolic
demands
• CPET involves measurement of
respiratory gas exchange: oxygen
uptake carbon dioxide output, and
minute ventilation
• In addition- monitor
electrocardiography, blood pressure
and pulse oximetry
Functional capacity is only
estimated through exercise testing?
• A) true
• B) false

False: Functional capacity can be assessed

through subjective questions and self
reported methods and through objective
exercise testing
A preop history of activities of daily living can
overestimate the true METs as measured by stress
testing?

• A) True
• B) False

False: it can underestimate

ISWT and 6min walk test are both
maximal exercise tests?
• A) true
• B) false

False: they are sub maximal tests

A distance of how many meters on
ISWT is associated with good
functional capacity?
• A) 200
• B) 250
• C)300
• D) 350

d) 350 mt corresponds to VO2 0f 11ml/kg/min

Stair walk test is a true indicator of
aerobic capacity?
• A) true
• B) false

False: it also tests lower limb stregth

Cpet can be done by pts with lower
limb pathology?
• A) true
• B) false

True: arm crank can be used instead of treadmill or bicycle

44 stairs equate to a VO2 peak of
approx. 20ml/kg/min?
• A) true
• B) false

False: 14ml/kg/min: mets>4

 Pulmonary function criteria suggesting increased
risk of post op pulmonary complications for various
surgeries
Thank you