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Pulmonary Function Testing: Overview and Practice Questions
by John Landry, BS, RRT | Updated: Aug 29, 2024
Pulmonary Function Testing (PFT) is a critical component in diagnosing,
managing, and monitoring respiratory diseases, providing a comprehensive
overview of lung function.
These noninvasive tests measure various lung capacities, volumes, and
flow rates, offering crucial insights into respiratory health and
identifying abnormalities in lung functionality.
PFTs are integral in assessing both obstructive and restrictive lung
diseases, assisting healthcare providers in determining disease severity,
evaluating treatment efficacy, and optimizing management strategies.
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This article provides a comprehensive overview of pulmonary function
testing, discussing the tests commonly performed, the parameters
measured, and their clinical application.
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What is Pulmonary Function Testing?
Pulmonary Function Testing (PFT) is a comprehensive set of tests designed
to assess lung function and respiratory performance, crucial for
diagnosing, managing, and monitoring respiratory diseases. PFTs measure
lung volume, capacity, flow rates, and gas exchange, offering vital
insights into the presence and severity of pulmonary conditions.
Indications
Pulmonary function testing is indicated for various reasons, primarily to
evaluate the respiratory system’s function and status.
Some of the primary indications include:
To assess changes in a patient’s pulmonary function
To evaluate the effectiveness of treatment
To diagnose pulmonary diseases
To assess the progression of pulmonary diseases
To differentiate between obstruction and restrictive diseases
To differentiate types of obstructions
To assess the risk of surgical procedures
To assess postoperative complications
To measure the effects of occupational exposure
To evaluate the patient’s level of fitness
To evaluate impairment or disability
Note: Each of these indications helps in establishing a diagnosis,
guiding therapeutic decision-making, and prognosticating outcomes,
ultimately enabling optimized patient-centered care in respiratory
medicine.
Contraindications
Pulmonary function testing is a vital tool in respiratory medicine but is
contraindicated under certain circumstances due to potential risks.
Some of the primary contraindications include:
Recent myocardial infarction
Unstable angina
Uncontrolled hypertension
Hemoptysis
Pneumothorax
Acute pulmonary embolism
Acute asthmatic attack
Acute COPD exacerbation
Recent cataract surgery
Note: Patient safety is paramount, and therefore, medical practitioners
must consider these contraindications to avoid any untoward complications
during or after Pulmonary Function Testing.
Types of Pulmonary Function Testing
Pulmonary function testing involves a group of tests that measure
different aspects of lung function.
Some of the primary types include:
Spirometry
Lung volume measurements
Forced vital capacity (FVC)
Maximal voluntary ventilation (MVV)
Maximal inspiratory/expiratory pressures (MIP/MEP)
Body plethysmography
Diffusing capacity
Cardiopulmonary exercise tests
Bronchoprovocation tests
Note: Each of these tests offers unique insights into pulmonary
function and can be selected based on individual patient presentation,
suspected diagnosis, and clinical indication to attain a comprehensive
evaluation of respiratory health.
Spirometry
Spirometry, a fundamental pulmonary function test, evaluates breathing
patterns and lung functionality using a spirometer—a diagnostic tool
measuring the volume and velocity of airflow throughout a breathing
cycle.
This test is instrumental in diagnosing conditions like chronic
obstructive pulmonary disease (COPD) and restrictive lung diseases.
Additionally, it gauges the efficacy of medications for asthma patients,
providing insights into the responsiveness and adaptability of the
respiratory system to therapeutic interventions.
Lung Volume Measurements
Lung volume measurements are integral to pulmonary function testing and
encompass the assessment of:
Tidal volume
Inspiratory reserve volume
Expiratory reserve volume
Residual volume
These volumes are measured using techniques like nitrogen washout, helium
dilution, and body plethysmography, offering a meticulous examination of
the lungs’ ability to hold air and aid in defining the nature and extent
of pulmonary impairments.
Forced Vital Capacity
Forced Vital Capacity (FVC) measures the total volume of air that a
patient can rapidly and forcefully exhale after a maximum inhalation.
This is helpful in determining if the patient has an obstructive or
restrictive lung disease.
This highly effort-dependent maneuver requires persistent coaching from a
respiratory therapist to ensure the reliability of results, providing an
in-depth perspective on lung functionality and respiratory constraints.
Body Plethysmography
Body plethysmography is a test that measures the total amount of air that
can be inhaled, as well as the volume of air that remains in the lungs
after exhalation (i.e., residual volume).
It confirms restrictive lung diseases that markedly decrease total lung
volume and uniquely measures residual volume, granting a comprehensive
view of lung capacity and the repercussions of pulmonary afflictions.
Maximal Voluntary Ventilation
Maximal Voluntary Ventilation (MVV) assesses the maximum volume of air a
person can inhale and exhale within a specific timeframe, requiring deep
and fast breathing for 12 seconds.
It is pivotal for assessing the comprehensive function of the respiratory
system, with decreased MVV indicating the presence of an obstructive lung
disease.
Maximal Inspiratory/Expiratory Pressures
Maximal Inspiratory and Expiratory Pressures (MIP/MEP) are crucial for
evaluating respiratory muscle strength, gauging the force generated
during maximal inhalation and exhalation.
MIP represents the maximal pressure generated during an inhalation
against an occluded airway, while MEP denotes the maximum pressure during
a maximal exhalation against an occluded airway.
Diffusion Capacity
The diffusing capacity for carbon monoxide (DLCO) is a test that
evaluates gas exchange in the alveoli of the lungs.
It involves inhaling a mixture of carbon monoxide (CO) and a tracer gas,
followed by a 10-second breath-hold maneuver, enabling healthcare
providers to determine the patient’s diffusion capacity.
It is frequently used to monitor conditions like pneumoconiosis, evaluate
obstructive diseases, and observe changes in lung function.
Cardiopulmonary Exercise Tests
Cardiopulmonary exercise tests, such as the 6-minute walk test (6MWT),
assess oxygen uptake, carbon dioxide production, and heart rate during
physical exertion, offering insights into the severity of respiratory
diseases.
The distance covered in the 6MWT correlates with the clinical outcomes of
several pulmonary diseases.
Bronchoprovocation Test
Bronchoprovocation tests, like the methacholine challenge test, assess
airway hyperresponsiveness or the narrowing of airways due to triggers
like allergens and irritants.
It simulates asthma effects by having patients inhale increasing
methacholine concentrations.
Significant changes in FEV1 during this test assist in the definitive
diagnosis of asthma.
Types of Lung Diseases
Lung diseases predominantly fall into two main categories:
Obstructive Lung Diseases
Restrictive Lung Diseases
Note: Distinguishing between these disease types is crucial in pulmonary
function testing as it enables healthcare practitioners to administer or
advocate for the most suitable treatment modalities based on the
identified condition.
Obstructive Lung Diseases
Obstructive lung diseases are characterized by conditions that impede the
effortless exhalation of air from the lungs.
This category of diseases leads to shortness of breath, attributed to the
constriction of the pulmonary airways, resulting in diminished flow
rates.
The mnemonic “CBABE” can aid in remembering the principal obstructive
lung diseases, representing:
Cystic Fibrosis
Bronchiectasis
Asthma
Bronchitis (Chronic)
Emphysema
Note: Patients with obstructive diseases usually experience trouble
breathing out fully due to airway obstruction, which can be due to
inflammation, mucus plugs, or structural changes.
Restrictive Lung Diseases
Restrictive lung diseases comprise conditions that hinder the lungs from
fully expanding during inhalation, thereby limiting the lung’s capacity
to fill with air.
Essentially, the lung’s ability to expand is restricted, culminating in
reduced lung volumes.
By default, pulmonary conditions that do not fall under the
classification of obstructive diseases are generally categorized as
restrictive lung diseases.
Restrictive lung diseases can be intrinsic, involving conditions like
pulmonary fibrosis, or extrinsic, involving conditions such as pleural
effusion or obesity, affecting the space around the lungs or the chest
wall’s ability to move.
Remember: Discerning the type of lung disease through pulmonary function
testing is essential in guiding effective therapeutic interventions for
managing respiratory conditions.
Normal Values for Pulmonary Function Testing
The PFT results of individuals with healthy, properly functioning lungs,
should generally fall within the following ranges:
FEV1: > 80% of predicted
FEV1/FVC%: ≥ 70%
Forced Vital Capacity (FVC): > 80% of predicted
Slow Vital Capacity (SVC): > 80% of predicted
Airway Resistance (RAW): 0.6-2.4 cmH2O/L/sec
Diffusing Capacity for Carbon Monoxide (DLCO): 20-25 mL/CO/min/mmHg
Peak Expiratory Flow Rate (PEFR): 10 L/sec
Exhaled Carbon Monoxide: < 7 for nonsmokers
Note: If a patient’s PFT results fall outside these normal ranges, it can
help healthcare practitioners figure out what kind of lung problem they
might have, the severity, and the most effective treatment options.
Equipment for Pulmonary Function Testing
Performing pulmonary function tests requires the use of a variety of
specialized tools and devices, such as:
Spirometer
Peak flowmeter
Body plethysmograph
Pulmonary gas analyzer
Oxygen analyzer
Gas-conditioning device
Blood gas analyzer
Silverman pneumotachometer
With advancements in technology, the incorporation of new and improved
PFT equipment into clinical practices is a continual process.
The devices listed above are some of the most prevalent examples used in
pulmonary function testing.
Pulmonary Function Testing Practice Questions
1. What is the purpose of pulmonary function testing?
To identify pulmonary impairment and quantify the severity.
2. What is a spirometer?
A device that measures volume and flow.
3. What are the three categories of pulmonary function tests?
1) Dynamic flow rates of gases through the airways, 2) Lung volumes and
capacities, and 3) The ability of the lungs to diffuse gases.
4. What are the three components of pulmonary function testing?
1) Performing spirometry for measuring airway mechanics, 2) Measuring
lung volumes and capacities, and 3) Measuring the diffusing capacity of
the lung.
5. What are the two general types of measuring instruments?
Instruments that measure gas volumes, and instruments that measure gas
flow.
6. What are the two major categories of pulmonary diseases?
Obstructive and restrictive pulmonary diseases.
7. What can disqualify a forced vital capacity trial?
A cough, an inspiration, a Valsalva maneuver, a leak, or an obstructed
mouthpiece.
8. What does an FEV1/FVC ratio of less than 70% indicate?
An obstructive impairment.
9. What is airway resistance (Raw)?
The difference in pressure between the ends of the airways divided by the
flow rate of gas moving through the airway.
10. What is the most commonly measured lung volume?
Vital capacity
11. What is the most commonly performed test in pulmonary mechanics?
Forced vital capacity (FVC)
12. What is the normal tidal volume amount for an adult?
500 to 700 mL
13. What is the normal value for ERV?
1,200 mL
14. What is the normal value for IRV?
3,100 mL
15. What is the normal value for peak expiratory flow?
9.5 L
16. What is the normal value for RV?
1,200 mL
17. What is the normal value for TLC?
6,000 mL
18. What is the normal value for VC?
4,800 mL
19. What is the normal value of FRC?
2,400 mL
20. What is the normal value of inspiratory capacity?
360 mL
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21. What is the predicted normal FEV1 for a 20-year-old man?
4.7 L
22. What is the predicted normal FVC for a 20-year-old man?
5.60 L
23. What is the primary problem in obstructive lung diseases?
Increased airway resistance
24. What is the primary problem in restrictive lung diseases?
Reduced lung compliance, thoracic compliance, or both.
25. What makes up the functional residual capacity (FRC)?
Expiratory reserve volume (ERV) and the residual volume (RV)
26. What pulmonary function test poses the greatest risk for fainting?
MVV
27. What test is used to measure FRC?
A lung diffusion test
28. What type of gas is used in a diffusion test?
Carbon monoxide
29. When a patient performs an FVC maneuver, how much volume in % should
be exhaled in the first second?
70%
30. When are flow rates measured?
Flow rates are usually measured during expiration.
31. When performing pulmonary function testing, what establishes test
validity?
The test should strictly follow testing procedures, it must ensure
patient effort and performance, and you must ensure equipment accuracy
and calibration.
32. When is bronchial provocation indicated?
When the patient’s history suggests episodic symptoms of hyperactive
airways and airway obstruction, such as seasonal or exercise-induced
wheezing.
33. Why is vital capacity reduced in restrictive lung diseases?
Because the patient’s inhaled volume is reduced.
34. When will an airway collapse most likely occur?
During forced exhalation
35. What is an example of a combined obstructive/restrictive disease?
Sarcoidosis
36. What is the FEV1?
The volume of gas expired in 1 second.
37. What is the FEV3?
The volume of gas expired in 3 seconds.
38. What is a description of obstructive lung diseases?
They have decreased flows and increased airway resistance.
39. What is a hallmark sign of restrictive lung diseases?
They have decreased volumes.
40. What is the main purpose of pulmonary function testing?
To differentiate between obstructive or restrictive diseases.
41. What is a description of restrictive lung diseases?
They have decreased volumes and decreased lung compliance.
42. What tests are used to determine FRC and RV?
Nitrogen washout, helium dilution, and the “body box.”
43. What values will remain normal in restrictive lung diseases?
Tidal volume, FEV1, FEF200, and PEFR.
44. What is a lung capacity?
A combination of two or more lung volumes.
45. What correlation exists between the measurement of pulmonary
mechanics and age?
A negative correlation
46. What correlation exists between the measurement of pulmonary
mechanics and height?
A positive correlation
47. What is the diffusing capacity of the lung?
The number of milliliters of gas that transfer from the lungs to the
pulmonary blood per minute for each 1 mmHg partial pressure difference
between the alveoli and pulmonary capillary blood.
48. What is the diffusing capacity of the lung for carbon monoxide
(DLCO)?
The difference between the volume of carbon monoxide inhaled and the
volume of carbon monoxide exhaled, considering the partial pressure of
carbon monoxide in the lungs at the time of measurement.
49. An exhalation of how long is acceptable for children younger than 10
years old?
3 seconds
50. What is the expiratory reserve volume (ERV)?
The total amount of gas that can be exhaled from the lung after a quiet
exhalation.
51. What is extrapolated volume?
The volume exhaled before the zero time point.
52. The FEF 25% to 75% is a measurement of what?
The flow during the middle portion of an FVC maneuver, or the time
necessary to exhale the middle 50%.
53. The Fleisch pneumotachometer measures what?
It measures the changes in pressure as gas flows through a minimal,
constant resistance.
54. Flow measuring devices are commonly called what?
Pneumotachometers
55. For baseline testing, patients should temporarily abstain from what?
Bronchodilator medications, short-acting bronchodilators, long-acting
beta-agonist bronchodilators, and oral therapy with aminophylline should
be stopped for 12 hours.
56. What four general principles should be considered during pulmonary
function testing?
Test specificity, sensitivity, validity, and reliability.
57. For volume measurements, standard reference values are provided by
what?
By a graduated 3.0 L calibration syringe.
58. FVC is an effort-dependent maneuver that requires what?
It requires careful patient instruction, understanding, coordination, and
cooperation.
59. How many attempts must be performed to indicate that an FVC is valid?
3 attempts
60. How often should a PFT machine be calibrated?
At least daily, although the best practice in many labs is to verify
accuracy before each test subject.
61. How to calculate minute ventilation?
Respiration rate x Tidal volume
62. How to calculate the % of error?
% error = mean measured value – reference value ÷ reference value x 100
63. What do you use to calibrate a PFT machine?
3.0 L calibration syringe
64. How can you measure residual volume?
When the FRC is known, RV can be calculated as the difference between FRC
and ERV.
65. What does it mean when a person cannot exhale at least 70% of their
VC in 1 second?
They have an airway obstruction.
66. What is the inspiratory capacity (IC)?
The maximum amount of air that can be inhaled from the resting end-
expiratory level or FRC. It is the sum of the tidal volume and
inspiratory reserve volume.
67. What is the inspiratory reserve volume (IRV)?
The maximum volume of air that can be inhaled after normal quiet
inspiration.
68. In what patients may the validity of measuring the forced vital
capacity be hindered?
Acutely ill patients or those who have recently smoked a cigarette.
69. Is tidal volume alone a valid indicator of the type of lung disease?
No
70. Is the TLC increased or decreased in an obstructive lung disease?
Increased
71. Is the TLC increased or decreased in a restrictive lung disease?
Decreased
72. What is maximal voluntary ventilation (MVV)?
An effort-dependent test for which the patient is asked to breathe as
deeply and as rapidly as possible for at least 12 seconds. It’s a test
that reflects patient cooperation and effort, the ability of the
diaphragm and thoracic muscles to expand the thorax and lungs, and airway
patency.
73. Measuring pulmonary mechanics is essentially assessing what?
The ability of the lungs to move large volumes of air quickly through the
airways in order to identify an airway obstruction.
74. Measuring what can identify the destruction of alveolar tissue or the
loss of functioning alveolar surface area?
The diffusing capacity of the lungs for carbon monoxide (DLCO).
75. What is peak expiratory flow rate (PEFR)?
The maximum expiratory flow rate in L/sec.
76. Plethysmography techniques apply what law?
Boyle’s Law
77. What do pneumotachometers measure?
Flow
78. Residual volume represents how much of the TLC?
20%
79. What is residual volume?
The volume of gas remaining in the lungs after a complete exhalation.
80. What is a restrictive pulmonary disease?
A broad category of disorders with widely variable etiologies but all
resulting in a reduction in lung volumes, particularly the inspiratory
and vital capacities; categorized according to origin skeletal/thoracic,
neuromuscular, pleural, interstitial, and alveolar.
81. The severity of pulmonary impairment is based on what?
A comparison of each patient’s measurement with the predicted normal
value for the patient.
82. The speed of lung expansion represents what?
The flow rate
83. To ensure validity, each patient must perform a minimum of how many
acceptable FVC maneuvers?
3
84. What is total lung capacity (TLC)?
The total amount of gas in the lungs after a maximum inspiration.
85. The validity of MVV depends on what?
The duration of the maneuver, which should be at least 12 seconds; the
breathing frequency, which should be at least 90/min; and the average
volume, which should be at least 50% of FVC.
FAQs About Pulmonary Function Testing
What is Pulmonary Function Testing Used for?
Pulmonary Function Testing (PFT) is instrumental in evaluating numerous
respiratory conditions, encompassing obstructive and restrictive lung
diseases. It serves to monitor the evolution of diseases and ascertain
the efficacy of administered treatments.
Typical pulmonary function tests encompass spirometry, measurement of
lung volumes and capacities, maximal voluntary ventilation, MIP/MEP, and
body plethysmography.
What is the Purpose of Pulmonary Function Testing?
Pulmonary function testing primarily aims to yield a comprehensive
analysis of an individual’s respiratory health, facilitating the
diagnosis and surveillance of diverse respiratory ailments.
By scrutinizing lung functionality and the responsiveness of airways,
medical professionals can devise precise diagnoses and formulate optimal
treatment plans tailored to individual patients.
Moreover, PFTs are pivotal in monitoring the trajectory of diseases and
assessing the response to different therapeutic interventions.
What is DLCO in Pulmonary Function Testing?
DLCO, denoting the diffusing capacity for carbon monoxide, is a pivotal
component of pulmonary function testing, evaluating the rate of gas
exchange across the alveolar-capillary membrane.
It is indispensable for diagnosing a spectrum of lung diseases and for
tracking alterations in disease states over time.
How Do You Read Spirometry or PFT Results?
Spirometry or PFT results are generally conveyed via graphs or tables,
with values juxtaposed against normative ranges based on age, sex,
height, and other pertinent parameters.
Conventionally, subnormal values are indicative of compromised lung
function, whereas elevated values might signify air trapping in the lungs
or augmented effort in breathing.
A pulmonologist or a respiratory therapist typically undertakes the
interpretation of spirometry or PFT results to ensure accuracy and
appropriateness in diagnosis and treatment planning.
Final Thoughts
Pulmonary function testing (PFT) is an indispensable tool in respiratory
care. It provides valuable insights into a patient’s lung function and
aids in the diagnosis, monitoring, and management of various respiratory
conditions.
Understanding PFT results allows healthcare professionals to make
informed decisions about treatment strategies, ensuring personalized care
tailored to each patient’s unique needs.