DR.

ROWSHNE JAHAN
MBBS(DMC), DTCD, MD (Chest Diseases)

Assistant

Professor (Respiratory Medicine)

NIDCH, Mohakhali, Dhaka

A 55 year male patient with a smoking history of 40

pack year complained of cough , progressive
shortness of breath & wheezing on mild exertion.
Examination of chest revealed few rhonchi. His chest
X-ray is normal .
For further evaluation what investigation do you prefer
to do as first choice?
A. Spirometry with reversibility
B. HRCT Scan of Chest
C. DLCO
D. CPET( Cardio- pulmonary exercise Test)

A - correct answer.
The spirometry of the
patient shows

Spirometry is a method of assessing

lung function by measuring the
volume of air that the patient can
expel from the lungs after a full
inspiration.
It provides objective information about
pulmonary function and assess the
results of therapy.

Best tool for measuring airflow obstruction and

thus making a definitive diagnosis of COPD & to
help differentiate asthma from COPD
To confirm objective evidence of airway
obstruction spirometry is an essential component.

To assess the severity of airflow

obstruction/restriction in lung diseases.
As a screening & epidemiological survey tool to
detect early COPD in smokers who may have few or
no symptoms
To monitor disease progression in COPD,ILD etc
To see response to therapy

To distinguish between obstruction and

restriction as causes of breathlessness

To screen workforces in occupational

environments

To assess fitness to dive

For pre employment screening in certain

professions

As a prognostic marker ( FEV1 ) in COPD

Pre-operative assessment

The following questions may be answered:

1.
How badly impaired is the patients lung
function?
2.
Is airway obstruction present?
3.
How severe is it?
4.
Does it respond to bronchodilators?
5.
Is treatment helping the patient?

6. How great is the surgical risk?

7. Is the patients dyspnoea due to cardiac
or pulmonary dysfunction?
8. Does the patient with chronic cough have
occult asthma?
9. Is obesity impairing the patients
pulmonary function?
10. Is the patients dyspnoea due to
weakness of respiratory muscles?

FEV1 - Forced Expired Volume in one

second. The volume of air expired in the
first second of the blow

FVC - Forced Vital Capacity. The total

volume of air that can be forcibly exhaled
in one breath

FEV1 / FVC ratio the fraction of air

exhaled in the first second relative to the
total volume exhaled

VC -

slow or relaxed Vital Capacity

A full breath exhaled in the patients own
time and not forced. Often slightly
greater than the FVC, particularly in
COPD

FEV6

a forced expired breath lasting

for only 6 seconds. This often
approximates the FVC but is easier to
perform in older and COPD patients.

PEFR- (Peak expiratory flow rate) is the

highest flow rate of expired air at the tip
of the flow volume curve
FEF25-75 (Mid expiratory flow rate) is the
average flow rate in between 25% & 75%
of FVC

Inspiratory reserve
volume
Total
lung
capacity

Inspiratory
capacity

Tidal volume
Expiratory reserve
volume

Residual volume

Vital
capacity

Two basic types of lung dysfunction can be

defined by spirometry:
Obstructive

defect
Restrictive defect

Airflow obstruction: Reduced FEV1/FVC%

Restrictive pattern: Small lung volume
(Reduction of TLC = Reduction of FVC)
When there is any question about the cause
of a reduced FVC, TLC should be measured.
But we cant measure it by doing spirometry
.

AT LEAST 3 ACCEPTABLE TESTS

Full inhalation before start of test
Satisfactory start of exhalation
Evidence of maximal effort
No hesitation
No cough or glottal closure during the first
second
Satisfactory duration of test
At least 6 seconds
Up to 15 seconds in patients with airflow
obstruction
No evidence of leak
No evidence of obstruction of the mouthpiece

Choose statistically acceptable lower

limits of normal.
Evaluate and comment on test quality.
Use FVC, FEV1, and FEV1 /VC% as the
primary guides for interpretation. Values
that are well above or well below the
lower limits of normal can be
interpreted with confidence. Interpret
borderline values with caution, using
clinical information to make decisions.

Volume, L

FVC

4
3
2
1

Time, secs

At first

look for FEV1/FVC

<70% Obstruction
Look for FEV1 to see the severity of
obstruction
FEV1
> 70%- Mild obs

> 60%- Moderate obs

> 50%- Moderate severe obs
< 50%- Severe obs

FEV1/FVC- >70%/ Normal

Restriction
Look for
FVC
> 80%
Normal
< 80%
Restriction

FVC may also be reduced in the

presence of airflow obstruction,
especially when exhalation time is
short.
When there is airflow obstruction and
FVC is reduced, the possibility of
restriction can usually be eliminated
with evidence of over inflation from
the physical examination or chest
radiograph.

Base line spirometry done

2 puffs of sulbutamol given
Spirometry done after 20 mins.
Two spirograms compared
If FEV1 improvement is 12% and 200ml
from the base line then the response is
positive

Spirometry in ILD
The aim of doing spirometry in ILD is to quantify disease
severity & to monitor disease progression.
A restrictive defect is the most frequent ventilator
abnormality in patients with pulmonary fibrosis which is a
common consequence of many ILD. The presence of air
flow obstruction may reflect coexistent COPD/ASTHMA.
Lung volume may be relatively preserved in smokers with
IPF due to coexisting emphysema with FEV1/FVC ratio
remaining normal.
Change in FVC has emerged as the serial lung function
measurement most consistently predictive of mortality.
A change in FVC of only 10% is needed to identify a true
change in disease severity.

 In

stage I asymptomatic patient ,a 15% decline

in FVC requires a treatment with corticosteroid.

In

stage II & III 65% decline in FVC needs

empiric trial of steroid treatment even if there
is no symptom.

 All

patients considered for surgery require

spirometry. In the absence of other
comorbidities, preoperative FEV1 2 L are at
low risk for complications from lobectomy or
pneumonectomy.
predicted post-lung resection FEV1 800 ml
or 40% of predicted FEV1 is associated with a
low incidence of perioperative complications.

high risk patients (predicted FEV1 700

ml ), and in those with boderline spirometry,
cardiopulmonary exercise test may be helpful.

In

Carcinoid

Conclusion
So spirometry is a powerful tool that can be
used to diagnose, follow & manage patients
with lung diseases when done in appropriate
setting.