Lung Function Tests

F MANYERUKE
INTRODUCTION
• A non-invasive method for evaluation of pulmonary function

• Not for definite diagnosis of disease but help diagnosis along with history,
physical examination and other paraclinical diagnostic method
 Diagnostic

•To evaluate symptoms, signs or abnormal laboratory tests

•To measure the effect of disease on pulmonary function
•To screen individuals at risk of having pulmonary disease
•To assess pre-operative risk
•To assess health before beginning strenuous physical
activity

Monitoring
INDICATIONS •therapeutic intervention
•Disease progression
•Monitor people exposed to injurious agents
•Drug adverse reactions

Disability/impairment evaluation

Public health
 Uncontrolled hypertension

Suspected presence of active TB other communicable

respiratory disease
Thoracic or abdominal surgery within recent 3 wks

MI or unstable angina within recent 6 wks

Contraindications
of Spirometry Respiratory distress

Active hemoptysis

Recent eye/ear surgery or ear drum perforation

Abdominal or thoracic aortic aneurysm

 Common cold (3 days ego)

Severe respiratory infection (3w)

Confounding
Smoking( 1hr)
factors
Heavy food (1hr)

Bronchodilator use
 TV :The volume of air inhaled &
exhaled at each breath during normal
quiet breathing
IRV: The maximum amount of air
that can be inhaled after a normal
Lung inhalation
volumes ERV: The volume of air that can be
forcefully expired following a normal
quiet expiration
RV: The volume of air remaining in
the lungs after a forceful expiration
 TLC: The total volume of the lungs

VC: The maximum amount of air that

can be exhaled after the fullest
Lung inspiration possible
capacities IC :The maximum of air that can be
inhale after end tidal position

FRC: The amount of air remaining in

the lungs after a normal quiet
expiration
 FEV1
FVC
FEV1/FVC
Most
important PEF
parameters
FEF25-75%
V-T Curve
F-V loop
FVC • Definition:
 Defined as the maximal amount of
air that can be exhaled forcefully
after a maximal inspiration.
 defines maximum volume of exchangeable air
in lung (vital capacity)
•forced expiratory breathing maneuver
•requires muscular effort and some patient training

initial (healthy) FVC values approx 4 liters

FVC -
•slowly diminishes with normal aging

forced vital significantly reduced FVC suggests damage to

lung parenchyma

capacity •restrictive lung disease (fibrosis)

•loss of functional alveolar tissue (atelectasis)

intra-subject variability factors

•age
•sex
•height
•ethnicity
FEV1
• Definition:
 The volume of air exhaled during the
first second of a forced expiratory
maneuver.
 normal FEV1 about 80% of FVC
FEV1/FVC% • Definition:
 The value expresses the volume of air
the worker exhales in one second as a
percent of the total volume of air that
is exhaled.
 Calculated by using largest valid
FEV1 and largest FVC even if they
are not from the same tracing.
 Find largest valid FEV1
 Find largest valid FVC
 Divide FEV1 by FVC
 Multiply by 100 to obtain
percentage.
FEF25-75% • Definition:
 The mean expiratory flow during the
middle half of the FVC
 More sensitive than FEV1.
 Considerably more variability than
FVC and FEV1.
 ATS recommends only be
considered after determining
presence and clinical severity of
impairment and should not be used
to diagnosis disease in individual
patients
PEF - Peak • measures airflow limitations in large (central) airways

Expiratory Flow • PEF measurements recommended for asthma management

rate  spirometry is recommended to help make the diagnosis of
asthma

• PEF not recommend to evaluate patients for COPD

 cannot measure small airway airflow limitations

• advantages of PEF tests

 measurements within a minute (three short breaths)
 uses simple, safe, hand-held devices that typical, costs $20

• disadvantages of PEF tests (compared to spirometry)

 insensitive to obstruction of small airways (mild or early
obstruction)
 PEF is very dependent on patient effort (large intra-subject
variability)
 mechanical PEF meters are much less accurate than
spirometers
 Volume in liters against time in
seconds

Provides an idea on the quality of

Volume the spirometer (shows duration of
Time Curve exhalation which must be >6 sec)

Shows degree of response to

bronchodilation
 Is determined by
plotting FVC as flow (in
liters per second)
against volume (in
liters)
Flow-
Volume
Curve
This curve is more
informative and easier
to interpret, as different
diseases produce
distinct curve shapes.
 The leftmost end of the curve represents
TLC.
The curve’s rightmost end represents
RV.
Its width represents FVC.
Flow-
Volume Its height represents PEF.
Curve
The distance from TLC to the 1-s mark
represents FEV 1 .
The descending slope reflects the FEFs.
 FEV1: % predicted >
80%
Criteria for
Normal FVC: % predicted >
Post-
bronchodilator 80%
Spirometry
FEV1/FVC: > 0.7 -
0.8, depending on age
Normal Trace Showing FEV1 and
FVC

5 FVC

Volume, liters
4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1

1 2 3 4 5 6

Time, sec
Obstructive disorders

Are characterized by diffuse airway narrowing secondary

to different mechanisms [immune related, e.g., bronchial
asthma, or environmental, e.g., chronic obstructive
pulmonary disease (COPD)]

Restrictive disorders

Are a group of disorders characterized by abnormal

reduction of the lung volumes, either because of alteration
in the lung parenchyma or because of a disease of the
pleura, chest wall or due to muscle weakness
SPIROMETRY

OBSTRUCTIVE DISEASE
Spirometry: Obstructive Disease

5 Normal
4
Volume, liters
3
FEV1 = 1.8L
2
FVC = 3.2L Obstructive
1 FEV1/FVC = 0.56

1 2 3 4 5 6
Time, seconds
Spirometric Obstructive spirometry is confirmed
Diagnosis of FEV1/FVC < 0.7
obstruction
Bronchodilator Provides the best achievable FEV 1
Reversibility (and FVC)
Testing Helps to differentiate COPD from
asthma
Must be interpreted with clinical history
- neither asthma nor COPD are
diagnosed on spirometry alone
SPIROMETRY

RESTRICTIVE DISEASE
 FEV1: normal or
mildly reduced
Criteria: FVC: < 80%
Restrictive
Disease predicted
FEV1/FVC: > 0.7
 Spirometry: Restrictive
Disease
Normal
5

Volume, liters
4

3
Restrictive
FEV1 = 1.9L
2
FVC = 2.0L
1
FEV1/FVC = 0.95

1 2 3 4 5 6
Time, seconds
Diseases Associated with a
Restrictive Defect
Pulmonary

• Fibrosing lung diseases

• Pneumoconioses

• Pulmonary edema

• Parenchymal lung tumors

• Lobectomy or pneumonectomy

Extrapulmonary

• Thoracic cage deformity

• Obesity

• Pregnancy

• Neuromuscular disorders

• Fibrothorax
 FEV1: < 80%
predicted
Mixed
Obstructive/
FVC: < 80%
Restrictive predicted
FEV1 /FVC: < 0.7
Mixed Obstructive and Restrictive

Normal

Volume, liters
FEV1 = 0.5L
Obstructive - Restrictive FVC = 1.5L
FEV1/FVC = 0.30

Time, seconds
Restrictive and mixed obstructive-restrictive are difficult to diagnose by
spirometry alone; full respiratory function tests are usually required
(e.g., body plethysmography, etc)
SPIROMETRY

Flow Volume
 Standard on most desk-
top spirometers
Adds more information
Flow Volume than volume time curve
Curve Less understood but not
too difficult to interpret
Better at demonstrating
mild airflow obstruction
Flow Volume Curve

Maximum
expiratory flow
(PEF)

Expiratory
flow rate
L/sec

TLC
FVC RV

Inspiratory
flow rate
L/sec

Volume (L)
Flow Volume Curve Patterns Obstructive
and Restrictive

Obstructive Severe obstructive Restrictive

Expiratory flow rate

Expiratory flow rate

Expiratory flow rate

Volume (L) Volume (L) Volume (L)

Reduced peak flow, Steeple pattern, Normal shape,

scooped out mid- reduced peak flow, normal peak flow,
curve rapid fall off reduced volume
 Spirometry: Abnormal Patterns

Obstructive Restrictive Mixed

Volume
Volume

Volume
Time Time Time

Slow rise, reduced Fast rise to plateau Slow rise to reduced

volume expired; at reduced maximum volume;
prolonged time to maximum volume measure static lung
full expiration volumes and full PFT’s
to confirm