PULMONARY FUNCTION TESTS
Pulmonary Function Tests: (Maher K. Tabba MD, MS)
Spirometry
Lung Volumes
Diffusion Capacity
Maximal Voluntary Ventilation (MVV)
Maximal Inspiratory Pressure (Pi max)
Maximal Expiratory Pressure (Pe max)
Arterial Blood Gas (ABG)
Walking Oxymetry
Bronchochallenge Tests
INDICATIONS:
Pulmonary Evaluation:
Presence of impairment
Type of Pulmonary dysfunction
Quantification of impairment in known disease
Monitor the progression of known disease
Monitor the treatment response of known
disease
Preoperative Assessment:
Estimate the risk for postoperative
complications (operability)
Tolerance for lung resection (resectability)
Disability Evaluation
LUNG VOLUMES & CAPACITIES:
Tidal Volume (VT):The volume of air entering the nose or mouth
per breath (500 ml).
Residual Volume (RV): The volume of air left in the lungs after a
maximal forced expiration (1.5L).
Expiratory Reserve Volume (ERV): The volume of air that is
expelled from the lung during a maximal forced expiration that
starts at the end of normal tidal expiration (1.5L).
Inspiratory Reserve Volume (IRV): The volume of air that is
inhaled into the lung during a maximal forced inspiration starting at
the end of a normal tidal inspiration (2.5L).
Functional Residual Capacity (FRC): the volume of air remaining
in the lungs at the end of a normal tidal expiration (3 L).
Inspiratory Capacity (IC): The volume of air that is inhaled into
the lung during a maximal forced inspiration effort that begins at the
end of a normal tidal expiration (VT+IRV=3L).
Vital Capacity (VC): The volume of air that is expelled from the
lung during a maximal forced expiration effort starting after a
maximal forced inspiration (4.5L).
Total Lung Capacity (TLC): The volume of air that is inhaled into
the lung after a maximal inspiration effort (5-6 L).
Spirometry:
Measures the lung volume change during forced breathing
maneuvers:
Forced vital capacity (FVC)
Forced expiratory volume in the first second (FEV-1)
Spirometry Obstruction Restriction
FEV-1 Decreased (--) Decreased (-)
FVC Decreased (-) Decreased (-)
FEV-1/FVC Decreased (definition) Normal & Increased
Obstructive Lung Diseases:
Emphysema & Chronic Bronchitis
Cystic Fibrosis
Asthma
Bronchiectasis
Some Interstitial Lung Disease: (combined)
Restrictive Lung Diseases:
Pre and Post Bronchodilator Spirometry:
Goal: to evaluate the reversibility of the airway obstruction.
Technique : repeat the spirometry after the treatment with
bronchodilator.
Criteria: required two criteria at the same time:
200 ml and 12% (both) change in either FEV-1 or FVC
Patient with Reversible Airway Obstruction responds to
treatment with:
• Bronchodilator (short & long acting)
• Steroid inhaler
Spirometry:
Detects the obstructive lesions in the major airways.
Characterizes the lesion:
A-Location of the lesion:
• Intrathoracic
• Extrathoracic
B-Behavior of the lesion during rapid inspiration and
expiration:
• Fixed
• Variable
Variable Intrathoracic Lesion:
Examples: Tracheomalacia & Intratracheal tumor.
Variable Extrathoracic Lesion:
Examples: Vocal cord paralysis, Goiter, and Tumor
Intra or Extrathoracic Fixed Lesion:
Examples: Tracheal stenosis & surgical stricture, and
compressing mass.
Lung Volumes:
Diffusion Capacity:
Estimates the transfer of oxygen in the alveolar air to the red blood cell.
Factors that influence the diffusion:
1) Area of the alveolar-capillary membrane (A)
2) Thickness of the membrane (T)
3) Driving pressure
4) Hemoglobin
A-Decreased:
1) Decrease the area of the diffusion:
Lung/lobar resection, bronchial obstruction, and IPF.
2) Increase the thickness of the alveolar-capillary membrane:
IPF, CHF, pulmonary vascular diseases
3) Decrease the driving pressure: smoking, CO exposure
4) Hemoglobin: Anemia, Hemoglobinopathy.
B- Increased:
• Pulmonary hemorrhage
• Polycythemia
• Early CHF
• Asthma
• Exercise
• Obesity
• Left to right shunt
Technique:
• He or CH4 to measure the alveolar volume (VA)
• CO to measure the diffusion capacity (DLCO)
• DLCO
• DLCO corrected to Hgb (DLCO corr Hgb)*
• DLCO corrected to CO
• Alveolar Volume
• DLCO adjusted to the alveolar volume (DLCO/VA)*
Walking Oxymetry:
Goal: detects the hidden diffusion defect.
Technique: check O2 saturation at rest, 4 mins and 6 mins walk.
Walking Oxygen Desaturation:
1. Diffusion defect.
2. V/Q mismatch
3. Shunt
Criteria for Oxygen Supplementation (Home Oxygen):
1. PO2 <55 or Oxygen Saturation <88%
2. PO2 <59 with:Pulmonary Hypertension or Polycythemia
Maximal Voluntary Ventilation (MVV):
Measures the ventilatory reserve
The subject breaths as hard and fast as possible for 10-15 sec, and then adjust it to 1 min.
MVV = FEV-1 times 35-40
Decreases:
•Poor effort
•Neuromuscular diseases
•Obstructive & restrictive lung diseases
•Heart diseases
•Obesity
Maximal Inspiratory Pressure (Pi max) & Maximal Expiratory Pressure (Pe max):
Goal: To measure the strength of the respiratory muscles.
Technique: the amount of pressure the subject can generate in:
Deep inspiration (inspiratory muscles): (Pimax)
Deep expiration (expiratory muscles): Pemax
Normal value: Pimax (-60) & Pemax (+120) cm H2O
Indications:
Neuromuscular diseases
Unexplained decrease in VC & MVV
Weaning (Pimax > -30)
Arterial Blood Gas:
Oxygenation (PO2 and FiO2) & Ventilation (PCO2 and PH)
Acid – Base balance (PCO2, HCO2, and PH)
Bronchochallenge Tests:
Goal: evaluate the airway hyperresponsivness (asthma).
Technique: Methacholine, Histamine, Cold, Exercise…etc.
Criteria: 20% decrease in baseline FEV-1
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Interprating The PFT
Types of PFT:
Evaluate Lung Mechanics:
Volume
Flow
Resistance
Compliance
Airway Hyperractivity
Evaluate Respiratory Muscles:
Maximal Voluntary Ventilation (MVV)
Maximal Inspiratory Pressure (Pi max)
Maximal Expiratory Pressure (Pe max)
Seating & Supine Spirometry
Evaluate Gas Exchange:
PO2 & alveolar-arterial oxygen pressure difference
Physiologic dead space ventilation
Diffusion capacity
Interpreting PFT:
General Approach to Interpretation:
A. Is the test interpretable? “garbage in, garbage out”.
B. Are the results normal?
C. What are the pattern and severity of abnormality?
D. What does this mean for this patient?
General Information:
Age & Sex
Weight
Diagnosis
The patient’s effort during the test
Does the study meet the ATS criteria (Acceptability & Reproducibility)
Pulmonary Functions:
Spirometry:
z FEV-1/FVC ratio
z FEV-1 & FVC
z Flow-Volume loop
z MVV & Pimax or Pemax
Lung volumes: (TLC, RV, RV/TLC ratio)
Diffusion Capacity: (DLCO corr Hgb, DLCO/VA).
Arterial Blood Gas
Comparison with previous study
Abnormal Pulmonary Function Patterns:
1. Obstructive
2. Restrictive
3. Neuromuscular weakness
4. Pulmonary Vascular
5. Poor Effort
