PULMONARY

FUNCTION TEST
Mark Joshua S. Cruz RTRP
History of PFT
Claudius Galen
• 129-200 A.D. – first recorded spirometry test was performed by
Greco-Roman physician Claudius Galen.

• 1800 – the measurement of the lung’s residual volume was

performed.
Giovannin Alfonso Borelli
• • He had a volunteer plug his nose to assure an accurate
measurement of lung volumes, and to prevent air from escaping or
entering from the nose.
• • He is believed to be the first person to have have a patient block the
nose, a technique that is still done to this day during spirometry
testing.
• • 1679 - the volume of air that can be inhaled in a single deep breath
was first measured.
James Watt
• • 1790 - invented the gasometer, a container that stores gas
Thomas Beddoes
• • He laid the foundation of “pneumotherapy” and used his research
to establish the "Pneumatic Institute at Clifton” for the treatment of
disease by inhalation.

• • Also known as the father of “Inhalation Therapy”

John Abernethy
• • He developed a method of collecting expired gas over mercury and
attempted to determine how much those gases had been used up by
the body. He thought this was important because exhaled oxygen
should be less than what is inhaled.
• • He also determined that exhaled oxygen would be higher in patients
with certain lung diseases.
• • He also measured a vital capacity (VC) of 3110
Sir Humphrey Davey
• • He was able to measure his VT at 210 ml. The VT seems of low,
although it may have been normal based on Davey's height and age.
• • He also calculated his residual volume to be about 600 ml.
• • Davey also devised a mechanism to determine how much oxygen
was utilized by the body and how much carbon dioxide his body
created
John Hutchinson
• • In 1846, John Hutchinson invented a water seal spirometer, with
which he measured the vital capacity of over 2000 subjects
• • He observed the relationship between height and lung volume and
that VC decreases with age, obesity and lung disease
• The Hutchinson Water Seal Spirometer
Josef Bruer and Ewald Hering
• • 1868 - E. Hering and J. Breuer described the effects of lung inflation
and deflation on breathing which is Known as the “Hering-Breuer refle
André Strohl
• • 1919 – French physiologist who suggested the use of Forced Vital
Capacity (FVC)
• • He is remembered for his role in the diagnosis of Guillain – Barré
Syndrome (GBS)
Robert Tiffeneau
• • A French pioneer of respiratory medicine, built upon this invention
around 100 years later following Hutchinson, creating a complete
diagnostic instrument for COPD.
• • The forced expiratory manoeuvre was first described by Tiffeneau
and Pinelli working in Paris (France), in December 1947, who
proposed measurement of the "pulmonary capacity usable on
exercise" (capacité pulmonaire utilisable à l'effort) (CPUE), the
maximal volume expelled in one second after a deep inspiration.
Pulmonary Function Testing
(PFT)
Identify pulmonary impairment and quantify the severity of pulmonary
impairment if present.

• What type of lung impairment is present?

• What is the degree of lung impairment? Is it reversible?
• Is therapy indicated?
• What treatments are most effective?
• Is rehabilitation feasible?
Purposes
1. Screening for the presence of obstructive and restrictive diseases.
2. Evaluating the patient prior to surgery- especially true in patients
– older than 65 years old
– are known to have pulmonary disease
– Obese
– have history of smoking, cough or wheezing
– will undergo anesthesia for a lengthy period of time
– will undergo abdominal or thoracic surgery
3. Evaluating the patient's condition for weaning form the ventilator
4. Documenting the progression of pulmonary disease- restrictive or obstructive
5. Documenting the effectiveness of therapeutic intervention
6. Epidemiological surveillance for pulmonary disease
Contraindications to PFT
• Patients with acute, unstable cardiopulmonary problems
• Patients who have nausea and who are vomiting or has hemoptysis
• Patients with recent cataract surgery
• Patients with pneumothorax or acute pulmonary embolism
• Patients who are acutely ill or who have recently smoked a cigarette
• Patients with acute chest or abdominal pain
• Inability to follow instructions
Two major categories of pulmonary disease

Obstructive Disease Restrictive Disease

Airways Lung parenchyma, thoracic
pump
Expiration Inspiration
Increased airway Decreased lung or thoracic
resistance compliance
Flow rates Volumes or capacities
PFT EQUIPMENTS
1. Volume-measuring devices — Spirometers
2. Flow-measuring devices —Pneumotachometers
1. Spirometers (Positive displacement –
volume)
Several types of spirometers are used to measure volume and flow
rates.
• Dry-rolling seal spirometer (horizontal piston)
– measures volume and time
• Water-seal spirometer (Collins, Stead-Wells)
– measures volume and time
• Electronic spirometer
2. Pneumotachometers (Flow)
• Turbine device (Wright respirometer)
– measures flow, and may display volume
• Pressure Differential (Fleisch) pneumotachometer
– measures flow and can be used to continuously measure VE
Peak Flow Meters
• Device used to measure Peak Expiratory Flowrate (PEFR) at the
bedside
• Patient exhales forcefully through a device which incorporates a
resistor and a moveable indicator
• Accuracy is affected by patient effort, moisture and debris
• Available in two flowrate range
• Low range PEFR – 300 to 400 L/min
• High range PEFR – 600 to 800 L/min
Finding Personal Best Peak Flow Number
• To identify the patient’s personal best peak flow measurement,
instruct the patient to record their peak flow every day, morning and
afternoon, for two to three weeks during a period when their asthma
is under control.
• The single highest measurement recorded during this time frame is
the personal best.
• This process should be repeated occasionally to identify changes in
the personal best peak flow number.
• Typical peak flow value for a healthy adult is 10 L/sec or 600 L/min
How to Measure Peak Flow
1. Move the indicator to the bottom of the scale.
2. Stand up or sit up straight
3. Take a deep breath filling up lungs (TLC) and hold your breath
4. Place mouthpiece in mouth, close lips around the mouthpiece
5. Blow hard and fast as possible
6. The indicator will move up and record the peak flow reading
7. Repeat the process two more times
8. Record the highest of the three measurement
• Green . This means “go.” The green zone is 80% to 100% of your highest peak flow reading,
or personal best. This is the zone you should be in every day. When your measurements are
in this zone, air is moving well through the large airways in your lungs. It means that you can
do your usual activities and go to sleep without trouble.

• Yellow. This means “caution” or “slow down.” The yellow zone is 50% to 80% of your
personal best. Measurements in this zone are a sign that your large airways are starting to
narrow. You may start to have mild symptoms, such as coughing, feeling tired, feeling short
of breath, or feeling like your chest is tightening. These symptoms may keep you from your
usual activities or from sleeping well.

• Red. This means “stop.” The red zone is less than 50% of your personal best. Readings in this
zone mean you have severe narrowing of your large airways. This is a medical emergency.
You should get help right away. You may be coughing, very short of breath, wheezing while
breathing in and out, or having retractions (the muscles between the ribs are working hard
to help you breathe). You may also have trouble walking and talking.
Plethysmograph (Body Box)
• Based on Boyle’s Law - pressure and volume vary inversely if temperature is
constant.
• Measures thoracic gas volume (TGV) (same as FRC) and airway resistance
(ratio of alveolar pressure to airflow)
• Patient pant with the shutter open and the flow is plotted against box
pressure that produces S-shaped curve on the oscilloscope. At end of normal
expiration the shutter closes and second curve is plotted from mouth pressure
against box pressure. Raw is calculated from the two curves.
• Advantage is it will more accurately measure FRC in obstructive patients
• Disadvantages include physical limitation, claustrophobia and patient may be
unable to pant acceptably.
COMPONENTS OF BODY
PLETHYSMOGRAPH
1. Cabinet - has a volume of approximately 600 liters and is large enough for
the subject to sit within. It is constructed largely of plexiglass to allow good
visibility of the the subject and reduces claustrophobia. It has an intercom
for communication between the Respiratory Therapist and the subject. It
has a vent that can e opened or closed by the operator as needed.
2. Measuring System
a. Pneumotachometer- measuring the ventilatory airflow
b. Shutter- when activated, occludes the mechanical airway of the pneumotachometer
c. Pressure Transducer- located between the shutter and the subject. It is used mainly
to measure mouth pressure.
3. Non- Constant Volume Plethysmograph ( Volume or Flow type ) - directly
measures the quantity of air that is forced to enter or leave the cabinet.

4. Constant Volume , variable pressure plethysmograph ( Pressure type)- It has

a pressure transducer connected to an opening in the cabinet wall. It directly
measures then cabinet pressure during subject's breathing

5. Recording System-used for plotting pressures measured by plethysmograph

against either ventilatory flow rates or cabinet volume changes.

6. Computer- is a recent development. It allows rapid assessment of subject's

performance and test results. It can allow the operator to control the " best
fit" tangent measurement for tracings generated during the test.
Recording Devices
• Kymograph
o Rotating drum on which maneuver is recorded on graph paper
o Plots volume (Y-axis) against time (X-axis)
o Inspiration will cause an upward deflection of the pen and expiration will
cause a downward deflection of the pen
o Displacement of the spirometer bell causes an equivalent movement of the
pen that records the movement of the paper
• X-Y Recorder
o Plots volume (Y-axis) against time (X-axis)
o Advantage is that it allows for recording of flow-volume loops
Gas Analyzers
Oyxgen Analyzers
Galvanic fuel cell
• Creates electron flow as a result of the oxidation/reduction of O2.
• Measures partial pressure, displays Fi02 as %
• Accuracy can be affected by water on the sensor, high system
pressures and changes in altitude.
• If unable to calibrate, change fuel cell.
Oyxgen Analyzers
Polarographic
• Operation is similar to a galvanic fuel cell except for the presence of a
battery used to polarize the electrodes.
• This type of device is analogous to the Clark electrode.
• Measures partial pressure, displays Fi02 as %.
• Accuracy can be affected by altitude, water and high pressure.
• If unable to calibrate, change the battery and check electrolyte level
(refill if low).
Troubleshooting of O2 analyzer
• If after setup of a ventilator, blender or Venturi system the 02 analyzer
reads higher or lower — recalibrate analyzer and then recheck
equipment.
• Must be accurate within 2% of the known value.
Gas Chromatography (absorption type)
• Allows for measurement of several different gases with one detector.
• Advantage: can analyze many gases at one time and is very accurate.
• Disadvantages: requires more time for analysis than some other types
of analyzers such as infrared
• Affected by water and CO2
• Can measure the following gases: Ne, O2, N2, CO
Mass Spectrometry
• Sample is drawn by a vacuum into an ionization chamber. The
individual gases are separated and analyzed.
• Advantages: rapid response time (can be affected by condensation),
capable of breath-by¬breath analysis, allows for multiple gas analysis
(He, N2, 02, CO,).
• Disadvantage: very expensive. large in size, and requires high degree
of maintenance.
• Most suitable for analysis of several patients at once rather than for
individual testing.
Carbon dioxide/Carbon monoxide
• Infrared absorption analyzer.
• Quick response for diffusion (DLco) measurement.
• Calibrate to room air (0%) and known concentration, or serial
measurements of different gases containing different levels of CO:
then re-zero. Then use "gain" to match readout to known
concentration or measurement levels.
• Condensation in the tubing would cause a slow response time.
Helium Analyzer
• Thermal conductivity (Wheatstone bridge).
• Measures percentage.
• Calibrate to room air (0%) and a known amount (10%), then re-zero.
Use gain to adjust known amount.

Nitrogen analyzer
• Geissler tube ionizer.
• Measures percentage. Provides breath-by-breath analysis
• Calibrate to zero with 100% Oxygen (0% N2) and a known
concentration.
Pressure Measuring Devices
Pressure Measuring Devices
a. Water Manometer or Barometer.
• Measures atmospheric (barometric) pressure.
• A glass column is completely filled with water and constructed with its lower
end below the surface of a water reservoir.
• Atmospheric pressure forces the water from the reservoir up the column.
• Pressure is read from the bottom of the meniscus.
b. Aneroid Manometer.
• Consists of a sealed metal container with a gear or spring mechanism that
responds to changes in pressure.
• Used in blood pressure cuffs and in ventilators to display pressures.
MIP/MEP Device (Pressure Manometer).
Maximum Inspiratory Pressure (MIP).
• Used to monitor and assess the readiness to wean in ventilator patients.
• Assesses the degree of respiratory muscle impairment in patients with
Gulllain-Barre and Myasthenia Gravis.
• Inspiratory pressures are described with negative (-) numbers.
1. Have patient exhale to residual volume (RV).
2. Then have patient breathe in as quickly and as hard as possible with the
inspiratory port occluded for 15 20 seconds.
3. Observe the pressure indicated on the manometer and repeat the maneuver 2
more times.
4. Measurements of < 20 cm H2O indicate inspiratory muscle weakness.
MIP/MEP Device (Pressure Manometer).
Maximum Expiratory Pressure (MEP).
• Helpful in evaluating a patient's ability to maintain an airway and clear
secretions (ability to cough effectively).
• Expiratory pressures are described with positive (+) numbers.
1. Patient inhales to total lung capacity (TLC).
2. Then have patient blast out air as quickly and as forcefully as possible with
the expiratory port occluded.
3. Observe the pressure indicated on the manometer and repeat the maneuver
2 more times.
4. Measurements of < 40 cm H2O indicate poor ability to clear airway
secretions.
Calibration and Quality Control
• All equipment must meet ATS – ERS standards
• Volume calibration and leak test are done using a large volume syringe (Super
Syringe). Daily calibration with a 3.0 L syringe:
o Accuracy ± 3.5% (Range 2.895 L – 3.105 L)
o Calibrate with flows between 2 and 12 L/sec
• Flow calibration is done using a rotameter
• Gas analyzers are calibrated to zero
• Recording devices are checked with stopwatch
• Pletysmograph is calibrated by rotameter for flow and barometer for pressure
Patient Assessment, History
Taking & Patient Preparation
Patient Assessment for PFT
• • The first step for PFT is a good pre assessment of the patient's
pulmonary system. This will be gathered by the physician's
examination early in the subject's care.
• • It is useful to repeat this type of assessment just prior to the
administration of any specific pulmonary function study.
• • A better interpretation of the study’s test data is possible if all the
significant and most recent information of subject's pulmonary
system is available in a single report
• BASIC INFORMATION- includes the name, age, gender, height in
stocking feet, race and current diagnosis. If at all possible, height and
weight should be measured at the time the study is performed. For
subject who cannot stand or has spinal injury, measure the arm span
between the tips of the middle finger when the subject's arm are
extended directly outward from each other.
• PERSONAL MEDICAL HISTORY- includes whether the subject has ever
has or has been told that he has allergies/ hay fever, asthma, chest
injury or surgery, recurring colds, pneumonia, tuberculosis, lung CA,
bronchiectasis, emphysema, chronic bronchitis
• MEDICATIONS PRESCRIBED FOR LUNG OR HEART PROBLEMS -
includes type of medications prescribed and for what problems they
are taken in. the dose prescribed, the schedule taken in and when
they were last taken or used.
• FAMILY HISTORY - includes the immediate family. Immediate family
member's history should be described as it relates to the disorders
listed earlier under the heading of the subject's personal medical
history.
• SMOKING HISTORY - includes the age smoking began, years smoked,
type of tobacco or other substance, past and current daily
consumption. Does the subject smoke or live with a smoker? If the
subject has quit, the date and reason for quitting.

• HOBBIES - can be useful. This is especially true if the bobbies include

the use of chemicals, art supplies or other possibly irritating or
poisonous substances

• PETS - a listing of types and numbers of pets are useful. This is true if
their presence can be linked to pulmonary symptoms ( eg. wheezing ).
Knowing whether they are maintained indoors or outdoors can be
significant.
• PLACE OF RESIDENCE - This can be useful in diagnosing certain
endemic diseases.

• OCCUPATIONAL HISTORY - A chronological history of the subject's

occupation should be taken . A description of the actual job,
exposures to fumes, dust, gases should be noted. A history of
employment in farming, mining, quarrying, textiles can be significant
to pulmonary problems
HISTORY OF SYMPTOMS ASSOCIATED
WITH PULMONARY DISORDERS
1. Cough - When does the subject experience coughing ( time of day
or year ) - Does coughing affect the subject's ability to breathe? - Is
blood or sputum produced?
2. Dyspnea- Does the subject experience problems with dyspnea? -
When is the dyspnea experienced? ( at rest, with exertion, after
what distance walked, number of stairs climbed ) - Does it occur at
night?
3. Wheezing - When does it occur? ( frequency, time of the day, with
exertion, cold air) - Is the wheezing linked to dyspnea that limits the
subject's ability to perform a certain TASK ?
Physical Assessment
OBSERVATION OF THE SUBJECT
- The shape and configuration of the subject's thorax should be observed
- The shape and configuration of the subject's thorax should be observed
- The pattern and effort of breathing should be noted.
- Noticeable wheezing ,strider, cyanosis ( central or peripheral ), digital
clubbing, signs of cor pulmonale ( distended neck veins, edema in
dependent limbs )
- Level of cooperativeness
• VITAL SIGNS - The subject's pulse , respiratory rate, blood pressure
shoud be noted

• AUSCULTATION - Their subject should be auscultated and any

abnormalities in the subject's breath sounds should be recorded.
With adventitious sounds such as wheezing, ronchi or crackles, the
intensity, location and relation of the sound to the breathing cycle
must be noted.

• RESULTS OF X - RAY EXAMINATION - Significant information should be

noted such as abnormal densities in the lung fields, hyperinflation,
loss os vascular markings, presence of bullae, flattened diaphragm etc
 General Administration of PFT
For successful PFT, two key factors are involved.
1. The skill of respiratory therapist administering the test
2. The cooperation of the patient

• The respiratory therapist should demonstrate a combination of

concern, forcefulness, patience, supportiveness, humor. firmness and
persistence are necessary for those who are less cooperative.
• Clear and simple instructions must be given to the subject
Preparation for PFT
A) For Inhaled Medication
- Hold these for 24 hours before appointment Serevent( Salmeterol )/
Foradil ( Formoterol ). Seretide/ Symbicort/ Oxis
- Hold these for 12 hours before appointment Atrovent ( Ipratrotium ),
Combivent/ Berodual
- Hold these 4-6 hours before appointment Theophylline, Ventolin
( Albuterol), Xopenex ( Levalbuterol ), Maxair ( Pirbuterol ) Alupent,
Metaprel, Metaproterenol, Brethair, Brethine ( Terbutaline ) Tornalate
( Biloterol ), Bronkosol ( Isoetharine), Isuprel ( Isoproterenol,
Primantene Mist
For Oral Medication
• Hold these medications for 24 hours before appointment
Theophylline, Doxopfylline ( Ansimar ), Antileukotriene ( Singulair,
Accolate )

• Hold these medications for 8 hours before appointment Volmax,

Ventolin, Proventil, Proventil repetabs ( Albuterol), Metaprel
( Metaproterenol ), Bricanyl, Bethaine ( Terbutaline )
EATING AND DRINKING
• The subject may eat a normal breakfast or lunch before appointment
BUT NOT EAT HEAVILY, DRINK ANY ALCOHOLIC BEVERAGE, OR ANY
PARTICULAR SPICY FOOD ( which may cause heartburn, indigestion or
reflux ) on the day of apointment.

• Hold these 8 hours before appointment: coffee, tea, cola drinks,

chocolates and other food containing caffeine
• SMOKING
- Abstain for at least 6 hours prior to examination. - Smoking on the day
of examination may affect the diagnostic validity of spirometry

• EXERCISE, COLD AIR

- Do not participate in any strenuous exercise on the day of evaluation.
Avoid excess exposure to very cold or very hot air on the day of the test
Preparation
• The subject should avoid wearing items of apparel that are tight or
restrictive ( necktie, botton shirt collar, tight belt, excessively tight
brassiere or girdle. any restrictive clothing worn should be loosened
or removed.
• The laboratory must place a clean, disinfected, new disposable
mouthpiece on a measuring system prior to testing.
• The spirometer must be calibrated prior to testing.
Preparation
• It is often helpful to explain to the subject what the test is designed to
measure. a demonstration by the respiratory therapist of how the
subject is to breathe may be helpful for effort dependent test as in
fvc.
• Use of nose clips by the subject is recommended for all tests.
• The mouthpiece should be positioned so that the subject's chin is
slightly elevated and the neck extended. once the mouthpiece is
inserted, the respiratory therapist should check to make sure that
there is no leak present. dentures may have to be removed in order
for the subject to use the mouthpiece effectively.
Preparation
• Coaching of the subject is very important. it should be firm,
enthusiastic and encouraging.

• Once the test is administered, its result must be evaluated. subject's

effort and cooperation are the primary sources of error evidenced by
poor reproducibility of results from repeated test. for subjects with
hyperreactive airways, the best result maybe on the well performed
first test. later test result may be poor due to bronchospasm triggered
by a maximal tlc level inspiration.
Three Basic Tests of Pulmonary Function
1. Spirometry (Flow Studies)
measures the dynamic flow rates of gases through the airways
2. Lung Volume Studies
measures the volumes and capacities of the lungs
3. Diffusing Capacity Of The Lung
measures the ability of the lungs to diffuse gases
SPIROMETRY
– Forced vital capacity (FVC)
– Forced expiratory volume in 1 second (FEV1)
– Other forced expiratory flow measurements
– Maximum voluntary ventilation

These measurements assess ability of lungs to move large volumes of air quickly
through airways
Slow Vital Capacity (SVC)
• Patient is instructed to take a maximal inspiration followed by a
maximal exhalation without force.
• The SVC will provide the important Volumes used to identify
Restrictive Disease.
• Decreased volumes indicate Restrictive Disease.
• Decreased Vital Capacity is the best indicator of RESTRICTIVE lung
disease.
Forced Vital Capacity (FVC) Maneuver
• Most common test of pulmonary mechanics
• Many measurements are made while patient
is performing FVC maneuver
• FVC is an effort-dependent maneuver
requiring careful patient instruction and
cooperation
• To ensure validity, each patient must
perform at least three acceptable FVC
maneuvers
Forced Vital Capacity (FVC) Maneuver
• FVC is the maximum amount of air that can
be exhaled as quickly and forcefully as
possible after a maximum inspiration
• It is measured by simple spirometry
• It is used to measure FEVs and flows
• FVC is decreased in both obstructive and
restrictive disease
The FVC is not a flow, it is a VOLUME and should be equal to the
SVC.

• If the FVC is smaller than the SVC, indicates obstructive disease.

• If the FVC cannot be completed in 3 seconds, indicates obstruction.
FVC maneuver will provide Flow
Rates used to identify Obstructive
Disease.

1) FEV1 — Forced Expiratory Volume in 1 sec.

2) FEF 200-1200 — Forced Expiratory Flow 200-1200.
3) FEF 25-75 — Forced Expiratory Flow 25-75.
4) PEFR — Peak Expiratory Flow Rate.
Flow Studies
Timed Forced Expiratory Volume ( FEV 0.5,
FEV1, FEV2, FEV3 )
• the volume of air exhaled within a specific time from the start of an
FVC manuever specifically, within the first 0.5,1,2 and 3 seconds.

• - FEV 0.5 and FEV1 relates to disorders in large upper airway

• - FEV2 relates to disorder in smaller bronchi and larger bronchioles
• - FEV3 relates to disorder in smaller bronchioles
Force Expiratory Volume Percent ( FEV
0.5%, FEV1%, FEV2%, FEV3% )
• the percent of the total FVC volume that was exhaled within a specific
time from the start of manuever specifically within the first 0.5,1,2,3
seconds
Forced Expiratory Volume (FEV1)
• Volume of gas expired in the first second of the FVC.
• Most individuals can exhale all of their air in about 2 seconds.
• A decreased FEV, is a good indicator of obstructive disease.
• FEV1 is reduced with both obstructive and restrictive lung diseases.
• Normal FEV1 = 5.6 L for average 20-year old man
Severity of obstruction (FEV1)
• Mild: 70% to 74% of predicted value
• Moderate: 60% to 69% of predicted value
• Moderately severe: 50% to 59% of predicted value
• Severe: 35% to 49% of predicted value
• Very severe: <35% of predicted value
FEV1/FVC ratio or FEV%.
• This is a ratio (percentage) of the relationship of FEV to FVC.
• FEV1/FVC x 100 = FEV/FVC ratio
• Normal values are:
50% to 60% of the FVC is exhaled in 0.5 second
75% to 85% of the FVC is exhaled in 1 second
94% of the FVC is exhaled in 2 seconds
97% of the FVC is exhaled in 3 seconds
FEV1/FVC ratio or FEV%.
• Decreased FEV 1.0/ FVC is the BEST indicator of OBSTRUCTIVE
DISEASE.
• Decreased values = obstructive disease.
• Normal values = not obstructive disease (may still be restrictive).
• If the FEV1 is decreased but the FEV1/FVC ratio is normal, then the
patient has restrictive disease only.
Forced Expiratory Flow 200 — 1200
(FEF 200-1200)
• FEF200-1200 is the average flow rate of the exhaled volume between
the 200-mL and 1200- mL portion of the FVC maneuver.
• It is measured on the spirograph tracing between the 200-mL mark
and the 1200-mL mark to determine the average flow rate from the
FVC.
• A normal value is 6 to 7 L/s (400 L/min).
Maximum Expiratory Flow Rate
( FEF 200- 1200 or MEFR 200-1200 )
• - the average expiratory flow rate between the first 0.2 and 1.2 liters
of the FVC volume
• - relates to disorders in the large upper airways
Forced Expiratory Flow 25% — 75%
(FEF 25-75).
• Average flow rate during the middle portion of the FVC.
• Decreased in the early stages of obstructive disease.
• Decreased values are associated with small airway obstruction.
• A normal value is 4 to 5 L/s.
Maximal Mid Expiratory Flow
( FEF 25- 75% or MMFR )
• - the average expiratory flow rate over the middle 50% of the FVC
volume
• - directly relates to disorders in smaller bronchi and larger bronchioles
Maximum End Expiratory Flow Rate
( FEF 75- 85% )
• - the average expiratory flow rate between 75- 85% of the FVC
volume.
• - relates to disorders in smaller bronchioles
FORCED EXPIRATORY FLOW ( FEF )
• - Forced Expiratory Flow at 25% ( FEF 25% or Vmax 25 ) - maximum
expiratory flow after the 25% of FVC has been exhaled.

• - Forced Expiratory Flow at 50% ( FEF 50% or Vmax 50 ) - maximum

expiratory flow after the 50% of FVC has been exhaled

• - Forced Expiratory Flow at 75% ( FEF 75% or Vmax75) - maximum

expiratory flow after the 75% of FVC has been exhaled
Peak Expiratory Flow Rate (PEFR)
• Peak flow is the maximum flow rate achieved during an FVC
• Effort dependent.
• It is decreased in obstructive diseases and normal in restrictive
disorders.
• Sometimes used to evaluate asthmatic patients, pre & post
bronchodilation.
• A normal value is 400 to 600 L/min (6.5 to 10 L/s).
Forced Inspiratory Volume ( FIV )
– the volume of inspiratory vital capacity manuever inhaled as rapidly
as possible.
Forced Inspiratory Flow Rate ( FIF )
•Peak Inspiratory Flow Rate ( FIF max and PIFR ) - the maximum inspiratory flow
rate achieved at any point during an FIVC manuever.
•Maximal Mid Inspiratory Flow Rate ( FIF 25%- 75% ) - the average inspiratory
flow rate over the middle 50% of the FIVC volume.
•Instantaneous Forced Inspiratory Flow Rate ( FIF 75%, FIF 50% and FIF 25%) –
the inspiratory flow rate at a specified point in the FVC manuever specifically at
75%, 50 % and 25% of the FVC volume
Flow-Volume Loop
• Displays the volumes and flow rates measured
during the FVC.
• Patient performs an FEV followed by an FIV.
• The flow rates are displayed on the vertical (Y) axis.
1) Expiratory flows are above the base line.
2)Inspiratory flows are below the base line.
• Volume is displayed on the horizontal (X) axis.
• Special measurement:
Vmax50 – flow at 50% of the VC – similar to the FEF25-75 (small airways)
Flow/Volume loop
With the use of a flow-volume loop,
the following values may be
measured:
(1) Peak inspiratory flow (PIF)
(2) Peak expiratory flow (PEF)
(3) FVC
(4) FEV0.5, FEV1, FEV3
(5) FEF25%–75%
(a) fixed upper airway obstruction,
(b) variable extrathoracic upper airway obstruction
(c) variable intrathoracic upper airway obstruction.
Restrictive
= skinny
and tall
loop.

Obstructive
= short and
wide loop.
Interpretation of Spirometry
Predicted Normal Values
• All measured values are compared with the predicted normal values
for that individual.
• The relationship is expressed as a percent.
Actual value / predicted value = % of predicted.
• Predicted values are primarily based on:
1) Age.
2) Height.
3) Sex/gender.
4) Race/ethnicity.
Classification of Spirometry Results:
ATS-ERS Standards
80 —100% of predicted Normal PFT
60 — 79% of predicted Mild disorder
40 — 59% of predicted Moderate disorder
< 40% of predicted Severe disorder
Example #1: The following results are
obtained from a 58-year-old woman.
  PREDICTED OBSERVED %PREDICTED
FVC (L) 5.10 3.30 64.7
FEV1 (L) 3.83 3.18 83
FEV1 / FVC (%) 70 96  

% Predicted = Actual or Measured or Observed / Predicted or Reference X 100

FVC %Predicted = 3.3 / 5.10 X 100 = 64.7%
FEV1 % Pred = 3.18 / 3.83 X 100 = 83%
Interpretation: The volume measurement (FVC) is decreased (65%) so there is a mild restrictive problem,
The flows (FEV1 and FEV1/FVC) are normal (83% of predicted) so there is no obstructive problem.
Diagnosis: Mild Restrictive only.
Example #2: The following results are
obtained from a 47 year old man.
  PREDICTED OBSERVED %PREDICTED
FVC (L) 6.10 4.99 81.8
FEV1 (L) 4.58 2.04 44.6
FEV1 / FVC (%) 70 41  

Interpretation: The volume measurement (FVC) is normal (80+%) so there is

no restrictive problem. The flows (FEV1 and FEV1/FVC) are decreased so
there is a moderate obstructive problem.
Diagnosis: Moderate Obstructive only. Recommend a post bronchodilator
study to see if the obstruction is reversible.
Example #3: The following results are
obtained from a 35 year old man..
  PREDICTED OBSERVED %PREDICTED
FVC (L) 5.0 1.5 30
FEV1 (L) 4.0 1.20 25.5
FEV1 / FVC (%) 70 80  

Interpretation: The volume measurement (FVC) is decreased (30%) so

there is a severe restrictive problem. Although the FEV1 is decreased
(25.5%), the FEV1/FVC is normal. This pattern is restrictive only.
Diagnosis: Severe Restrictive only
Remember
a. Restrictive only (decreased volumes: VC or FVC).
b. Obstructive only (decreased flows: FEV1, FEV1/FVC).
c. Both Obstructive & Restrictive (decreased flows & volumes).
d. Neither Obstructive nor Restrictive (normal volumes & flows).
Obstructive Diseases: Restrictive Diseases:
Result in decreased flow studies result in decreased volumes (FRC,
(FEV1, FEV/FVC, FEF25%-75%, FVC, IC, IRV) and a normal FEV/FVC
FEF200-1200) and increased FRC, 1)Inflammatory diseases.
TLC, and RV values.
2) Cardiac disease.
1) Cystic fibrosis.
3) Neurological/neuromuscular.
2) Bronchitis.
4) Pleural disease.
3) Asthma.
5) Thoracic deformities.
4) Bronchiectasis.
6) Post-surgical patients.
5) Emphysema.
7) Fibrotic diseases.
Obstructive and Restrictive Disorders
9

Obstructive and Restrictive Disorders

 HIGH

HIGH HIGH

HIGH HIGH

HIGH HIGH HIGH

1. FEV1/FVC or FEV1% If Decreased = Obstructive
2. FVC If Decreased = Restrictive
3. FEV1/FVC or FEV1% AND FVC DECREASED = COMBINED
10

Reversibility
• If obstruction is present, reversibility must be evaluated
• Done by performing spirometry before and after therapy
• Bronchodilator is administered by smallvolume nebulizer or MDI
• Reversibility indicates effective therapy
 Before-and-After Bronchodilator Studies
• Used to determine the reversibility of lung dysfunction and the
effectiveness of the bronchodilator.
• Patients, most commonly those with asthma, are instructed to
perform a peak flow test before administration of a bronchodilating
agent. The value is recorded. The administration of the agent is
followed by another peak flow study.
• Reversibility of obstructed airways and improved flow rates are
considered significant if increases in flow studies are at least 12%.
Before-and-After Bronchodilator Studies

• An increase in either FEV1 or FVC ≥12% after bronchodilator

administration generally indicates reversibility of airway obstruction
(at least 200-ml increase in FEV1)
BRONCHODILATOR ADMINISTRATION
• - a bronchodilator is administered to subject after a baseline PFT has
been performed usually a sympathomimetic bronchodilator using a
small volume nebulizer or metered dose inhaler
• - A proper guideline for aerosol administration must be observed
1. Appropriate breathing pattern ( slow, deep inspiration within 3-5 seconds
inspiratory pause)
2. If MDI is used, there should be a delay of at least 5-10 minutes between puffs.
• - Once a bronchodilator has been administered, there should be a delay
before the post administration test is performed. A 10-15 minutes
delay for sympathomimetic bronchodilator.
10

Bronchoprovication
• Indicated when the patient’s history suggests episodic symptoms of
hyperreactive airways and airway obstruction
• Uses an agent to stimulate a hyperreactive airway response and to
create airway obstruction
– Methacholine provocation protocol systematically exposes the patient to
increasing dosages of methacholine
Methacholine Challenge Test
• Determines the degree of airway reactivity to methacholine, a drug that
stimulates bronchoconstriction
• May be performed in a before-and-after bronchodilator study or before
exercise-induced asthma studies
• The objective of the test is to determine the minimum level of methacholine
that elicits a 20% decrease in FEV1
• Other parameters can be used. They include FEF 25-75%, FEF 50% and FEF
max. A 25% reduction is significant. SGaw can be used. A 35% being
considered significant.
• A physician should be present during testing, and bronchodilators and
resuscitation equipment should be readily available
Provocation Studies
• PREPARATION
1. The subject should be asymptomatic for a bronchoconstricitve study.
2. The subject should be currently capable of performing an FEV1 that
is at least 80% of the best previous value. A baseline test should be
performed to ensure that the subjects current capabilities are at an
acceptable level.
3. As with the bronchodilator benefit study, the subject should abstain
from using medications that have been prescribed to manage
bronchospasm. The length of abstinence varies depending upon the
type of medication in question
TEST ADMINISTRATION
• Metacholine Chloride used maybe prepared in advance from 25mg/
ml stock. Most dose mixture are relatively stable and can be stored up
to 2 weeks if refrigirated. The initial dose should be approximately 0.1
mg/ml with the largest dose being approximately but no greater than
25mg/ml.

• For histamine, the maximum dose is 10 mg/ml. With both substances,

a normal subject can tolerate doses of this level without developing
significant reduction in pulmonary function
• A standard small volume nebulizer can be used but for a greater control of
the dose, a dosimeter should be used to control the nebulizer system. A
dosimeter provides a controlled flow to the nebulizer only during inspiration.

• The first aerosol administration is of neutral control agent usually normal

saline. Five sow maximal deep inspiraton from the FRC level should be taken
from the aerosol with 3-5 seconds end inspiratory hold at the end of each
inspiration.

• Three minutes after the aerosol administration, an FVC is performed. The

FEV1 measured from this test will serve as a control FEV1 value ( FEV1-C ).
The FEV1-C must be acceptable in order for the study to continue. It must be
at least 90% of the initial baseline value measured earlier.
• Individuals with very highly reactive airways may have a > 20%
reduction in FEV1 at this point. This is considered to be positive even
if the first actual dose of metacholine was never administered.
• If the value of the FEV1-C is acceptable, then five breaths of the first
small dose of metacholine is administered. Three minutes later, an
FVC test is again performed and the test’s FEV1 ( FEV1-T ) is
evaluated.
• The FEV1- T’ s percent of decrease from FEV1-C should be determined
using:
Once the FEV-T Decrease is calculated, there
are 3 possible outcomes
1. The FEV1-T is clearly reduced to a value that is more than 20% less
than the FEV1-C value. This constitute a positive reaction to
metacholine.
2. The FEV1-T is reduced to a value nearly 20% less than the FEV1-C
value without representing a clearly positive result. This represents
a borderline reaction.
3. The FEV-T is clearly not reduced to a value that is 20% less than the
FEV-C. This represents a negative reaction to metacholine.
Preoperative Pulmonary Function
1. To assess the risk of morbidity and mortality associated with
performing surgical procedure on patient
2. To predict post-operative pulmonary function for patients who are
being evaluated for possible lobectomy or pneumonectony
3. To plan the patient's care including preparation and preoperative
therapeutics, management of anaesthesia during surgery and post
operative therapeutics.

* Patients scheduled to receive thoracic and/ or abdominal surgical

procedures are often assessed
• ABSOLUTE INDICATIONS
1. A history of smoking
2. Active symptoms of pulmonary disorders ( dyspnea and/or cough and
sputum production)
3. Abnormalities identified during physical procedures ( eg. abnormal x-ray,
breathing rate or pattern, breath sounds )
• CONDITIONAL INDICATIONS
1. Demonstrating evidence of current or recent pulmonary infections or who
have significant pulmonary infections
2. Morbidly obese
3. Demonstrating evidence oh having problems with debilitation or
malnutrition
4. Advanced in age ( 70 years old and older )
• Any subject demonstrating below normal preoperative FVC value
regardless of the cause is an increased surgical risk. Postoperatively,
VC value will reduce further due to the effect of anaesthesia, pain etc.
When this is combined with preoperative reduction, the patient
maybe left with severe postoperative impairment of cough function
EVALUATION OF THE STUDY RESULT
• The dose at which a positive 20% reduction in FVE1 is demonstrated is
considered the Provocative dose ( PD 20% FEV1 )
• -There is a more specific way which PD 20% FEV1 can be reported.
This can be done by reporting a cumulative value for PD 20% FEV1 by
determining the number of cumulative dose units ( CDU ) of
metacholine that had been administered to the subject in the
following manner
CDU= ( 1st dose concentration x 5 breaths ) + ( 2nd dose concentration
x 5 breaths ) + ( 3rd dose concentration x 5 breaths ) up to the dose
that produce a positive reaction
• Report the CDU value as a function of the cumulative minutes of time
needed to produce a response.
PD 20% FEV1 = 5.78 CDU’s / 12 minutes
The final report provocation study should include
1. The provocative substance used
2. Whether the study provides a positive or negative result

If the study were positive

3. The nature of the subject’s positive reaction
4. The test parameter ( s ) that was ( were ) monitored
5. The last actual measured test parameter value and the value for the PD
20% value for that test parameter
Exercise Induced Asthma
• - This is designed to evaluate the amount of bronchospasm that may
occur in the subject as a result of vigorous exercise.
• - Cooling of the respiratory tract mucosa is thought to be the primary
triggering mechanism. The increase in ventilation that occur during
exercise is responsible for the loss of heat from the mucosa of the
respiratory tract. The heat loss is proportional to the level of
ventilation- greater ventilation results in greater heat loss.
• - At any level of ventilation, a subject is more likely to have a
bronchospastic reaction to breathing cold dry air.
Maximum inspiratory pressure (MIP)
• This measurement is also referred to as negative inspiratory force
(NIF).
• represents the maximum amount of negative pressure a patient can
generate during inspiration.
• A normal MIP is approximately -50 to -100 cm H2O.
• A patient who cannot generate at least -20 cm H2O of pressure has
inadequate respiratory muscle strength.
Maximal expiratory pressure (MEP)
• A normal MEP is 90 to 100 cm H2O.
• Patients unable to generate an MEP of at least 40 cm H2O of pressure
are not able to maintain adequate spontaneous ventilation or
secretion clearance, which makes mechanical ventilation necessary.
Sniff Nasal Inspiratory Force ( SNIF )
• A polyethylene catheter ending in a plug is attached to pressure
transducer and the plug end is inserted into the nostril. The
contralateral nostril is occluded and the patient is instructed to exhale
to FRC then close his mouth and take a deep sniff or maximal
inspiratory effort. The highest of the 6 recorded pressures sustained
for at least 1 second is reported.

• Result: SNIF of less than 40 cm H20 is associated with hazards of

death
Exhaled Nitric Oxide (FENO) Analysis
• NO is produced as a gas by macrophages, eosinophils, and endothelial
and epithelial cells. It is present in exhaled air.
• It increases when airway inflammation occurs and is a valuable
method to both diagnose and manage asthma.
• NO levels help assess the response to corticosteroids used to treat
asthma as well as help determine the proper dosage and
discontinuation of the drug.
• Certain factors influence FENO levels; therefore patients need to
refrain from exercise, alcohol, smoking, and eating at least 1 hour
before testing.
• Steroids and beta agonists affect the level of FENO; therefore the
drugs and last time of administration should be recorded before
testing.
• FENO levels should be tested before forced expiratory maneuvers
because they decrease the FENO level.
• The patient inhales NO-free air through the analyzer as deeply as
possible (TLC) and exhales slowly. The test should be done three
separate times to ensure quality testing. Acceptable efforts are those
when three values are within 10% or two values are within 5% of each
other.
• Normal FENO value in adults is <25 ppb (parts per billion) and <20
ppb in children. Values above 50 ppb in adults and 35 ppb in children
may indicate an increased risk of acute exacerbation, poor treatment
compliance, poor MDI technique, or inadequate steroid dosage
LUNG
VOLUMES &
CAPACITIES
Lung Volumes Lung Capacities
• Tidal volume • Total lung capacity
• Inspiratory reserve volume • Inspiratory capacity
• Expiratory reserve volume • Functional residual capacity
• Residual volume • Vital capacity
Lung Volumes Lung Capacities
• Tidal volume • Total lung capacity
• Inspiratory reserve volume • Inspiratory capacity
• Expiratory reserve volume • Functional residual capacity
• Residual volume • Vital capacity
Tidal volume (VT)
• The volume of air (usually in milliliters) that is inhaled or exhaled
during a normal breath
• The exhaled VT is usually measured with a respirometer at the
bedside or by spirometry
• VT is decreased or normal in restrictive disease and increased or
normal in obstructive disease
• A normal value is 400 to 700 mL (or 3 to 4 mL/lb of ideal body weight,
or 5 to 6 mL/kg)
Inspiratory reserve volume (IRV)
• IRV is the maximum volume of air that can be inspired after a normal
inspiration.
• IRV normally is not measured during simple spirometry, but if it is, it
should be measured from a slow vital capacity.
• IRV could be normal in both obstructive and restrictive disease;
therefore its measurement is not clinically significant.
• A normal value is 3000 mL.
Expiratory reserve volume (ERV)
• ERV is the volume of air exhaled after a normal expiration.
• ERV is measured directly by spirometry from a slow VC (i.e., VC 2 IC).
• ERV may be normal or decreased in obstructive or restrictive disease.
• A normal value is 1000 mL and 20% to 25% of the VC.
Residual volume (RV)
• RV is the volume of air left in the lungs after a maximal expiration.
• It is derived after FRC is calculated, with the use of either the nitrogen
washout test or helium dilution test.
• Once FRC is calculated, subtract the ERV from FRC; this equals the
residual volume (i.e., RV = FRC - ERV).
• RV is increased in obstructive disease and decreased in restrictive
disease.
• A normal value is 1500 mL.
Functional residual capacity (FRC)
• FRC is the amount of air left in the lungs after a normal expiration
(i.e., ERV + RV).
• It is measured by the helium dilution or nitrogen washout test or by
body plethysmography
Indirect Spirometry
- used in the determination of lung volumes not measurable by direct spirometry
- RV, FRC, TLC
1. Helium Dilution
2. Nitrogen Washout
3. Body Plethysmograph
FRC Measurement
Helium Dilution (Closed Method).
1. A spirometer is normally filled with about 600 mL of gas with about 10%
helium added to the volume. The volume of the gas and the concentration
of helium are measured and recorded before the test.
2. The patient is instructed to breathe normally and, at the end of a normal
exhalation, is connected to the system.
3. The patient rebreathes the gas in the spirometer while CO2 is removed by
a CO2 absorbent.
4. Helium is then diluted until equilibrium is reached. This normally takes
about 7 minutes, but in patients with severe lung disease, it may take as
long as 30 minutes for equilibrium to occur. Equilibrium occurs as the
helium analyzer falls to a stable level.
FRC Measurement
Helium Dilution (Closed Method).
5. The final concentration of helium is then recorded

He1= helium concentration before patient is connected to the system

He2 = final helium concentration when equilibrium has occurred
BTPS correction factor = constant to convert volume to body temperature and
pressure saturated
Helium Dilution Method for Measuring Functional Residual Capacity
FRC Measurement
Nitrogen Wash Out (Open Method).
• The nitrogen concentration in the lungs is approximately 79% at the
beginning of the test, which is gradually washed out as the patient
breathes 100% O2.
• The patient is instructed to breathe normally, and at the end of a
normal exhalation, the patient is connected to the 100% O2 breathing
system.
• During the procedure, the exhaled volume is monitored and recorded
and nitrogen percentages are measured.
• Complete nitrogen washout occurs in about 7 minutes.
Nitrogen washout
method for
measuring
functional residual
capacity, residual
volume, and total
lung capacity.
FRC Measurement
Nitrogen Wash Out (Open Method).
• FRC may now be calculated with the use of the following formula:

• N1 = nitrogen percentage in lungs at start of test

• N2 = nitrogen percentage in spirometer at end of test
FRC Measurement –
Plethysmograph/Body Box.
1) Uses Boyle's Law to determine total thoracic gas volume at FRC.
2) Patient pants at FRC while pressures and volumes are obtained.
3) Measures gases trapped inside the lung
4) Airway resistance (Raw) can be determined by measuring the changes in
Pressure vs. Flow
Normal airway resistance: 0.6 — 2.4 cm H20/L/sec.
5) Lung compliance can be determined by measuring the volume change per
unit pressure change in L/cmH2O or mL/cmH20.
Normal lung compliance: 60 —100 mL/cmH20.

Most accurate method to measure FRC in COPD patients

Body
Plethysmography
Method for
Measuring Lung
Volumes.
FRC Measurement –
Plethysmograph/Body Box.
• FRC can then be calculated as:

• Body plethysmography also measures thoracic gas volume (VTG), TLC,

and RV.
• FRC is increased in obstructive disease and decreased in restrictive
disease.
• A normal value is 2500 mL.
TYPES OF PLETHYSMOGRAPHY
1. Body Plethysmography - requires that the subject's entire body be
enclosed within the boxlike cabinet during testing.
2. Inductive Plethysmography- involves the use of sensors that are
strapped around the subject's thorax and abdomen
Inspiratory capacity (IC)
• IC is the maximum amount of air that can be inspired after a normal
expiration (i.e., VT + IRV)
• IC is measured by simple spirometry from VC
• It is usually decreased or normal in obstructive or restrictive disease
• A normal value is 3500 mL (75% to 85% of the VC)
Vital capacity (VC)
• VC is the maximum amount of air that can be exhaled after a
maximum inspiration (i.e., VT + IRV + ERV)
• It is measured by simple spirometry or at the bedside with the use of
a respirometer
• VC is decreased in restrictive disease and is normal or decreased in
obstructive disease
• A normal value is 4800 mL
• A decreased VC may be the result of pneumonia, atelectasis,
pulmonary edema, pulmonary fibrosis, kyphoscoliosis, or lung cancer.
Forced vital capacity (FVC)
• FVC is the maximum amount of air that can be exhaled as quickly and
forcefully as possible after a maximum inspiration
• It is measured by simple spirometry
• It is used to measure FEVs and flows
• FVC is decreased in both obstructive and restrictive disease
Total lung capacity (TLC)
• TLC is the amount of air remaining in the lungs at the end of a
maximal inspiration
• It is calculated by a combination of other measured volumes
• TLC is decreased in restrictive disease and increased in obstructive
disease
• A normal value is 6000 mL
RV/TLC (ratio)
• This is the percentage of the TLC that remains in the lungs after a
maximal expiration
• It is measured by dividing the RV by TLC and multiplying by 100 to get
a percentage
• RV/TLC is normal in restrictive disease and increased in obstructive
disease
• A normal value is 20% to 35%
Maximum Voluntary Ventilation (MVV)
Maximum Voluntary Ventilation (MVV)
• The largest volume and rate that can be breathed per minute by
voluntary effort. The patient is told to breathe in and out as fast as
possible until told to stop. Performed for 12 —15 seconds.
• This measurement tests for overall lung function, ventilatory reserve
capacity, and air-trapping.
• Decreased with obstructive disease, increased airway resistance
(Raw), muscle weakness, decreased compliance, and poor patient
effort.
• Normal value is 170 L/min (may be calculated by using the following
formula: 40 X FEV1).
Gas Diffusing Capacity (DLCO, DC0)
• Represents the gas exchange capabilities of the lungs.
• This measurement evaluates how well gas diffuses across the
alveolar-capillary membrane into the pulmonary capillaries.
• The most common method for measuring DL is the single-breath
method.
Single-breath Method
• The patient is connected to a system in which the inspired gas contains a
mixture of 10% helium and 0.3% carbon monoxide (CO). CO is used
because of its increased affinity for hemoglobin (Hb), which keeps the
partial pressure of CO in the capillaries low, and because it diffuses
rapidly across the alveolarcapillary membrane.
• The patient is instructed to exhale completely to the RV level, place the
mouthpiece in the mouth, inhale as deeply as possible, hold the breath
for 10 seconds, and then exhale.
• The DLCO (carbon monoxide diffusion capacity), or the measurement of
the amount of CO diffusing from the alveoli to the pulmonary blood flow
Concentration of
alveolar carbon
monoxide after a
single breath to
total lung
capacity
Gas Diffusing Capacity (DLCO, DC0)
• Normal diffusion capacity is approximately 25 to 30 mL/min/mm Hg.
• Decreased DLco (decreased diffusion) occurs in patients with:
1) Pulmonary fibrosis.
2) Sarcoidosis.
3) ARDS.
4) Pulmonary edema.
5) Emphysema (the only obstructive disease).
• If DLCO is less than 80% of normal — diffusion defect is present
ØReduced surface area = emphysema
ØThickened AC membrane = pulmonary fibrosis
V/Q scanning
• This radiograph evaluates the relationship of the distribution of
ventilation to pulmonary perfusion in the lungs.
• For the determination of gas distribution, the patient inhales the
radioactive isotope xenon and holds the breath for 10 to 20 seconds.
Radiographs (photoscintigrams) are obtained to observe how the
xenon was distributed in the lung.
• For the determination of pulmonary perfusion, the patient is injected
with a radioactive iodine preparation and photoscintigrams are taken
as the blood perfuses the lungs.
Pulmonary Function
Changes in Advanced
Lung Diseases
Quality Assurance for
Spirometry
1. Patient performance standards (ATS — ERS)
2. Equipment performance standards
1. Patient performance standards
(ATS — ERS).
SVC maneuver
• All patients should be carefully instructed in the procedure.
• The therapist should demonstrate the procedure for the patient.
• A minimum of three (3) acceptable procedures should be recorded
that are:
a) Free from artifacts.
b) Have good starts.
c) Show satisfactory exhalation for a minimum of 6 seconds.
1. Patient performance standards
(ATS — ERS).
FVC maneuver.
• All patients should be carefully instructed in the procedure.
• The therapist should demonstrate the procedure for the patient.
• A minimum of three (3) acceptable procedures should be recorded.
o No false starts.
o Tests should not differ by more than 5% or 200 mL.
• The best test should be determined and used for reporting results.
o Best test is the trial that results in the largest sum of FVC + FEV1.
2. Equipment performance standards
• Volume-measuring devices (spirometers) must be capable of
1) Measuring volumes up to 8 liters.
2) Recording expiratory maneuver for a minimum of 30 seconds.
• Flow measuring devices (pneumotachometers) must be capable of
recording expiratory maneuver for specified time depending upon
test performed.
1) SVC - 30 sec.
2) FVC —14 sec.
3) FEV1 —1 sec.
Quality Assurance for PFT
• The whole purpose of PFT is to generate physiologic measurement
data that correctly reflects the current state of pulmonary system.
once available, the data is often used to make important evaluations
and decisions regarding subject's health.

• Unless a great effort is made in maintaining the quality in all factors

that affect the measuring process, the measurement data that are
generated become worthless
THREE THINGS THAT MUST BE EVALUATED WITH
EACH TEST TO ASSURE QUALITY OF TEST
1. Technologist performance- relate to how the technologist followed
the approved laboratory procedure for administering the test.
2. Equipment performance- relates to whether the equipment
functioned as designed and and intended during the administration
of a test.
3. Subject performance- relates to how effectively the subject
understood, cooperated and performed during the test procedure.
THE TECHNOLOGIST IS THE KEY TO
TEST THE QUALITY ASSURANCE.
• Honest, critical self evaluation should be done with each test as he
performs. It is also his responsibilty to evaluate the performance of
the equipment and the subject during each test. This requires critical
obbservation of the equipment, subject and the data produced.
Concerns that must be evaluated before
finalizing a result
1. Did the equipment perform optimally?
2. Did the subject perform optimally?
3. Does the test result satisfy the criteria for acceptability for the particular test
performed?

IF NO IN ANY OF THE MENTIONED

4. Attempt to correct the equipment and/ or subject difficulty and repeat the affected test.
5. Decide that the measurements at least acceptably reflect the subject's capabilities and
report the data. However, the report should include the nature of the concerns the
technologist had regarding the test procedure and the result.
6. Report that testing was attempted but acceptable results could not be generated
A SAFE MAXIM IN PFT IS THAT IT
IS BETTER TO REPORT NO
RESULTS THAN TO REPORT
INCORRECT RESULTS
EQUIPMENT QUALITY ASSURANCE
• a process which ensures that the measuring tools used in pulmonary
function testing are functioning at least at minimally acceptable levels
of performance or better.

Key factors of equipment quality assurance

1. Good maintenance of equipment
2. Routine performance of calibration
3. Quality Control procedures
Maintenance
1. Preventive maintenance- consists of maintenance procedures that are
performed on a scheduled basis in order to avoid breakdowns or problems
with the equipment.
2. Corrective maintenance- performed whenever there is a breakdown in a
piece of equipment. This includes adjustments or repairs, servicing by the
medical personnel, biomedical technologist or staff from the
manufacturer.
• A record should be kept. It contains the date and types of preventive and
corrective maintenance performed.
• * Following any maintenance, a calibration and/ or quality check of the
equipment should be made
Calibration
is a process that makes a precise measuring instrument function so that the
results correctly reflect the actual value of what is being measured.
Steps in Calibration
1. Using the instrument to make a measurement of a test signal ( sample
that has a known, fixed value)
2. Making a calibration adjustment on the instrument so that the
measurement results are equal to the fixed, known test signal value

* Given a precise instrument, calibration performed prior to instrument use

will make the instrument accurate.
Quality Control
periodic challenging of a calibrated instrument to confirm the accuracy
of the measurements that are being made. This serves as a double
check of instrument and avoids any assumptions.

* In order to be effective, the measuring system should be both precise

and and accurate
• Precision- refers to how reproducible measurements are when testing
is repeated, even if the results are not correct. A precise instrument
will, with each attempt at measurement, consistently provide the
same result, even if it is a wrong value. However, if a precise
instrument could be adjusted to provide a correct result, the outcome
would be an instrument that will consistently provide a correct result.
•
• Accuracy-refers to how close the results of measurements are to the
correct actual value of what is being measured. This is based upon
how closely the mean of series of measurements approximates the
actual value of what is being measured
Equipment for generating an appropriate
Calibration or Quality Control Test Signal
1. Calibrated Syringe
- is a precise , manually operated large volume syringe that has a
known volume. For calibration and quality control purposes, the
volume of the syringe must be 3.0 liters or greater.
- can be used to provide test signal for both the primary- volume type
and primary flow type spirometer system.
- a variation of this type is the COMPUTERIZED SYRINGE with a
microprocessor and timing mechanism that integrates the volume
output of the syringe with the time taken during the output and
reveals the flow rate of a gas.
2. Automated Syringe
- calibrated syringe that are motor driven to provide automated control
of both the volume output and flowrate
Problems that can affect the operation of
spirometer
1. Leaks in spirometer's tubing or tubing connections
2. Incorrect timing calibration of spirometer's recording mechanism
3. Defective analog to digital interfacing between the spirometer and
the computer or its software.
4. Incorrect calibration of spirometer. This could relate to incorrect
establishment of the spirometer's analog signal gain, ATPS/BTPS
correction and software correction factor
Problems that can relate to Primary Volume
Measurement Spirometer
1. Cracks and leaks in the structure
2. Mechanical resistance to the movement of spirometer's component
3. Low water level in water- sealed spirometer
4. Incorrect translation of the movement of spirometer into an analog
signal by potentiometer
Problems that relate to Primary Flow Measuring Spirometer
1. Obstruction of the flow sensor by dirt or other material

Problems that can affect Body Plethysmograph Operation

2. Leaks in the door seals or tubing connections
3. Incorrect calibration of the plethysmograph's pressure or flow transducer
4. Obstruction or damage to the plethysmograph's pressure or flow
transducer
5. Poor flow or pressure transducer performance as a result of vibration from
being loosely mounted
6. Poor frequency response of the plethysmograph's measuring system
7. Excessive thermal drift within the plethysmograph's cabinet
Standards for Spirometer
VITAL CAPACITY- The spirometer should
be able to
1. Measure volumes at least 7 liters
2. Accumulate volumes at least 30 seconds
3. Measure volumes accurately at air flow rates between 0 - 12 L/sec
(Flow measurement must be linear within this range )
4. Measure volumes accurately to at least within ± 3% or 50 ml whichever
is greater

FORCED VITAL CAPACITY- same as for VC except that the spirometer should
be able to accumulate volumes for at least 15 seconds although longer
times are recommended
TIMED FORCED EXPIRATORY
VOLUMES
same as for FVC but additionally
1. Resistance to gas flow should be less than 1.5 cm H2O/ l/ sec at
flow rates of 12 l/ sec
2. The “Start Test" used to indicate the start of timing will be
determined by the back extrapolation method
a. Hand Measurement- extrapolation back from the steepest slope on
volume/ time curve
b. Computer- largest average value for slope over a 70 msec period
FORCED EXPIRATORY FLOW ( FEF 25%-
75% )
- same as for FVC and FEVt but additionally
The accuracy of flow measuremant should be at least ± 5% or ± 0.2 l/
sec, whichever is greater

FLOW - where flow/ volume loops or other uses of flow measurements

are made, the flow measurement accuracy at flow rates of ± 12 l/sec
should be within ±5% of the reading or ±0.2 l/sec, whichever is greater.
MAXIMUM VOLUNTARY VENTILATION
( MVV )
- the spirometer should be able to
1. Have an over-all accuracy of ± 10% of the reading when challenged
with a 0-4 hz sine wave air flow input of 12 l/sec over the volume
range
2. Make measurements of no less than 12 seconds or more than 15
seconds and have time based accuracy of ± 3%
3. Function with a back pressure resistance to breathing of less than ±
10 cm H20. This is for 2 hz sine wave gas flow input of 2 liter volume
RECORDING AND DISPLAY SYSTEM
A: FVC Volume / Time Tracings- To satisfy these standards, the recorder
should display the following
1. Diagnostic use
a. Volume measurements with a unit size of at least 5 mm/l of volume
b. Time scale of at least 1 cm/ sec

2. Validation/ Hand Measurement use

c. Volume Measurements with a unit size of at least 10 mm/l of volume
d. Time scale of at least 2 cm/ sec with a preferred scale of at least 3 cm/ sec
when hand measurements are to be made
FVC FLOW/ VOLUME Tracings
To satisfy these standards, the recorder should display the following
1. Exhaled volume upward and exhaled flow to the right
2. A scale ratio of 2:1 ( flow: volume ) between the flow and volume scales ( eg. 2 l/sec
and 1 liter unit sizes should be the same distance on each respective axis )
3. For diagnostic use, minimum resolution and scale factor of at least
a. 0.050 liter and 5 mm/l for volume
b. 0.20 l/sec and 2.5 mm/l/sec for flow
c. 20 msec and 1 cm/ sec for time
4. Validation and Hand Measurement
a. 0.025 liter and 10 mm/l for volume
b. 0.10 l/sec and 5 mm/l/sec for flow
c. 20 msec and 2 cm/sec for time
3 satisfactory and consistent tests
• Complete inspiration
• Complete expiration performed without interruption
• No air expired before the forced inspiration
• Maximum expiratory flow (6 secs)
• Absence of cough
Accceptability Criteria
• Good start = extrapolated volume <0.15 L
• Good end = Force exp. Time > or equal to 6 secs
• No artifact = smooth curve
Reproducibility
• 3 acceptable test
• The largest FEV1 and the second largest FEV1 must not vary by more
than 0.2 L
Principles of Measurement and Significance
For tests of pulmonary function, three general principles should be
considered:
1. Test sensitivity and specificity
Address the test’s ability to detect disease, or absence of it
2. Validity
Relates to its meaningfulness, or the ability to measure what it is intended to
measure
3. Reliability
Consistency
Infection Control in PFT
• • Handwashing must be performed between testing sessions with the
subjects and before and after handling any subject- related
equipment
• • Use bacterial filter at the subject connection. Filters can retain
excessive moisture from exhaled air and may begin to produce a
resistance to air flow.
• • The mouthpiece of the breathing circuit must be changed between
subjects. Breathing circuit tubing and valves will often also have to be
changed
Infection Control in PFT
• • The primary flow measuring spirometer has a flow sensor placed
near the subject connection. It should be cleaned daily..
• • Gloves and other protective barrier should be used by the
technologist in removing the mouthpiece from the breathing circuit
after it has been used on subjects with documented infection.
• • It is important to document that laboratory's infection control
practice is being successful. This is done by performing regular
infection surveillance procedures by routinely culturing swab sample
from clean reusable equipment and occasional on new disposable
equipment
Severity of Pulmonary Impairment Based on
a Percentage of Predicted Normal Values
Pulmonary Function Changes in Advanced
Lung Diseases
Classification of Spirometry Results:
ATS-ERS Standards
80 —100% of predicted Normal PFT
60 — 79% of predicted Mild disorder
40 — 59% of predicted Moderate disorder
< 40% of predicted Severe disorder
PFT Normal Values & Degree of Impairment
• mild restrictive pattern with moderate decrease in gas exchange
FVC%Change = (4 – 3.3) / 3.3 = 0.21 x 100 = 21%
FEV1 %Change = ( 2.5 – 2) / 2 = 0.25 x 100 = 25%

• Moderately severe obstructive pattern with hyperinflation responsive to

bronchodilator
FEV1 %CHANGE = (2.2 – 2)/2 = 0.1 x 100 = 10%

moderately severe obstructive pattern with hyperinflation and airtrapping not responsive to
bronchodilators.
• moderate obstructive pattern not responsive to bronchodilators.
• A. Mild restrictive lung disease
• B. Severe restrictive lung disease
• C. Mild obstructive lung disease
• D. Severe obstructive lung disease
• The physician wants to know whether a new bronchodilator would be
helpful to the patient with asthma. The physician orders a before-and-
after bronchodilator study. The patient has the following peak flow
values: 7.5L/min before the medication and 9.4L/min after the
medication. Calculate the patient’s percentage change
A. −25%
B. 1.25%
C. 25%
D. 80%
Post – Pre / Pre
9.4 – 7.5 / 7.5 = 0.25 x 100 = 25%
1. VT
2. IRV
3. FVC
4. IC
5. ERV
Which of the flow-volume loops
represents a fixed large-airway
obstruction?
A. Tracing A
B. Tracing B
C. Tracing C
D. Tracing D
%Pred = Actual/Ref
3.6 / 4.2
0.857 X 100 = 86%
A. Airway obstruction is responsive to bronchodilator therapy.
B. Airway obstruction is nonresponsive to bronchodilator therapy.
C. Inadequate patient effort was exerted; the test needs to be repeated.
D. The restrictive disease is nonresponsive bronchodilator therapy
%Change = Post –Pre / Pre
= 2.8 – 2.15 / 2.15 = 0.30 = 30%
Which of the following pulmonary function data are consistent with a
restrictive lung disease pattern?
I. an FVC 70 % of predicted dec FVC
II. a TLC 68 % of predicted dec vol dec cap
III. an FEV1/FVC ratio of 50 % dec is OBS
A. I, II only
B. II only
C. I, IV only
D. I, II, III
In an obstructive lung disorder, which of the following occurs?
1. FRC is decreased no
2. RV is increased yes
3. VC is decreased
4. IRV is increased
a. 1 and 3 only
b. 2 and 3 only
c. 2 and 4 only
d. 2, 3, and 4 only
Which of the following expiratory maneuver findings are characteristic
of restrictive lung disease?
1. Normal FVC
2. Decreased FEF25%–75%
3. Increased PEFR
4. Decreased FEVT
a. 1 and 3 only
b. 2 and 4 only
c. 3 and 4 only
d. 2 and 3 only
• indicates restrictive lung disease
• severe obstructive ventilatory impairment
restrictive lung disease