Pulmonary Function Testing Riham

Raafat

Pulmonary Function testing:

-Definition:
Valuable tool for the evaluation of the respiratory system, representing
an important adjunct to the patient history, various lung imaging studies,
and invasive testing such as bronchoscopy and open-lung biopsy. The
overall approach is to compare the measured values for an individual
patient at any particular point in time with normative values derived from
population studies to assess physical fitness and working abilities.

-Significance:
a. Help in diagnosis and differentiation of many respiratory diseases
(restrictive and obstructive lung disorders, diagnose exercise
induced asthma, differentiate chronic bronchitis from BA)
b. Explain the cause of symptoms in patients who are diseased and
clinically normal (as early detection of small air way disease)
c. Assessing the course of the disease and effect of therapy (as
steroids with BA and radiotherapy with cancer)
d. Objective quantitative measurements of lung damage due to
occupational injury
e. Pre-operative assessment

-Classification:
a. Tests of ventilatory function:
 Evaluate lung volumes and capacities:
o Spirometry (FVC, FEV1, FEF25-75, MVV)
o Body plethysmography
o Gas dilution method (FRC and RV detection)
 Evaluate hypersensitivity: broncho-provocative test

1
Pulmonary Function Testing Riham
Raafat

b. Tests for gas exchange: tests of diffusion (DLCo, ABGs) Oximetry

for O2 saturation and Capnography for trans-cutaneous CO2
c. Tests for lung compliance
d. Tests for resistance and impedance: impulse oscillometry
e. Breath condensate
f. Cardio-pulmonary stress tests (CPX) and assessment of respiratory
muscle strength
g. Assessment of regional lung functions

[A] Spirometry:
-Definition: It is a physiological test that measures how an individual
inhales or exhales volumes of air as a function of time. The primary
signal measured in spirometry may be volume (in liters) or flow (in L/s).
Spirometry is invaluable as a screening test of general respiratory health
as it does not lead clinicians directly to an etiological diagnosis.

-Types: Spirometry can be undertaken with many different types of

equipment, and requires cooperation between the subject and the
examiner, and the results obtained will depend on technical as well as
personal factors.

2
Pulmonary Function Testing Riham
Raafat

a- Volumetric spirometry:  Wet rolling sealed spirometer

 Bellows wedge spirometer
 Dry rolling sealed spirometer
b- Flow measuring spirometry:  Hot wire pneumotachygraphy S.
 Flow resistive pneumotachygraphy S.
 Lilly spirometry (screen)
 Turbine spirometry
 Pito spirometry
 U/S spirometry
-Indications:
Diagnostic
 To evaluate symptoms, signs or abnormal laboratory tests
o Symptoms: dyspnea, wheezing, orthopnea, cough, phlegm
production, chest pain
o Signs: diminished breath sounds, overinflation, expiratory slowing,
cyanosis, chest deformity, unexplained crackles
o Abnormal laboratory tests: hypoxemia, hypercapnia, polycythemia,
abnormal chest radiographs
 To measure the effect of disease on pulmonary function
 To screen individuals at risk of having pulmonary disease
o Smokers
o Individuals in occupations with exposures to injurious substances
o Some routine physical examinations
 To assess pre-operative risk
 To assess prognosis (lung transplant ...etc.)
 To assess health status before beginning strenuous physical activity
programs

3
Pulmonary Function Testing Riham
Raafat

Monitoring
 To assess therapeutic intervention
o Bronchodilator therapy
o Steroid treatment for asthma, interstitial lung disease, etc.
o Management of congestive heart failure
o Other (antibiotics in cystic fibrosis, etc.)
 To describe the course of diseases that affect lung function
o Pulmonary diseases (Obstructive airway diseases, ILD)
o Cardiac diseases (Congestive heart failure)
o Neuromuscular diseases (Guillian-Barre Syndrome)
 To monitor people exposed to injurious agents
 To monitor for adverse reactions to drugs with known pulmonary
toxicity

Disability/impairment evaluations
 To assess patients as part of a rehabilitation program (medical,
industrial, vocational)
 To assess risks as part of an insurance evaluation
 To assess individuals for legal reasons

Public health
 Epidemiological surveys
 Derivation of reference equations
 Clinical research

-Relative contraindications:
 Hemoptysis of unknown origin,
 Pneumothorax,
 Unstable angina pectoris, or recent myocardial infarction,
 Thoracic or abdominal or cerebral aneurysms,

4
Pulmonary Function Testing Riham
Raafat

 Recent eye surgery (increased IOP during forced expiration),

 Recent abdominal or thoracic surgical procedures, and
 Patients with a history of syncope associated with forced exhalation.

-Technique:
.Spirometry requires a voluntary maneuver in which a seated patient
inhales maximally from tidal respiration to total lung capacity (TLC) and
then rapidly exhales to the fullest extent until no further volume is
exhaled at residual volume (RV).

.The maneuver may be performed in a forceful manner to generate a

forced vital capacity (FVC) or in a more relaxed manner to generate a
slow vital capacity (SVC).

.In normal individuals, the inspiratory vital capacity, the expiratory SVC,
and expiratory FVC are essentially equal. However, in patients with
obstructive airways disease & in non-cooperable patients, the expiratory
SVC is generally higher than the FVC (as forced expiration will increase
airway narrowing and air trapping & needs subject's effort respectively).

.Equipment quality control: (ATS)

5
Pulmonary Function Testing Riham
Raafat

. To record FVC:
 Check the spirometer calibration

 Explain the test

 Prepare the subject:

o Ask about smoking, recent illness, medication use, etc.
o Measure weight and height without shoes

 Wash hands

 Instruct and demonstrate the test to the subject, to include:

o Correct posture with head slightly elevated
o Inhale rapidly and completely
o Position of the mouthpiece (open circuit)
o Exhale with maximal force

 Perform maneuver (closed circuit method)

o Have subject assume the correct posture
o Attach nose clip, place mouthpiece in mouth and close lips around
the mouthpiece
o Inhale completely and rapidly with a pause of 1s at TLC
o Exhale maximally until no more air can be expelled while
maintaining an upright posture (It is important for subjects to be verbally
encouraged to continue to exhale the air at the end of the maneuver to obtain
optimal effort reaching the expiratory plateau)
o Repeat instructions as necessary, coaching vigorously
o Repeat for a minimum of three maneuvers; no more than eight are
usually required
o Check test repeatability and perform more maneuvers as necessary

 Perform maneuver (open circuit method)

o Have subject assume the correct posture
o Attach nose clip
o Inhale completely and rapidly with a pause of 1s at TLC
o Place mouthpiece in mouth and close lips around the mouthpiece
o Exhale maximally until no more air can be expelled while
maintaining an upright posture
o Repeat instructions as necessary, coaching vigorously
o Repeat for a minimum of three maneuvers; no more than eight are
usually required
o Check test repeatability and perform more maneuvers as necessary

6
Pulmonary Function Testing Riham
Raafat

-Performance standard for office spirometer: (ATS)

 Volume Spirometer Should:

o Accumulate volume for greater than 30 s

o Accommodate volumes of up to 7 liters
o Be accurate to within 3% or 50 ml of a "test" volume
 Flow-Sensing Spirometer Should:
o Be able to measure flows up to 12L/s
o Be accurate to within 5% or 0.2 L/s
 Both Need:
o Regular maintenance
o Routine checks of accuracy of the spirometer and the
computer
- Acceptability and Reproducibility Criteria: (ATS)
Reproducibility criteria Acceptability criteria
(Between maneuver criteria) (within maneuver criteria)
.After 3 acceptable spirograms Individual spirograms are
have been obtained, apply the "acceptable" if:
following tests: .They are free from artifacts:
-Are the two largest FVC within  Cough or glottis closure
0.2 L of each other? (valsalva) during the first
-Are the two largest FEV1 within second of exhalation.
0.2 L of each other?  Early termination or cutoff
If both of these criteria are met,  Variable effort
the test session may be concluded.  Leak (sp. With volume types)
.If both of these criteria are not  Obstructed mouthpiece
met, continue testing until: . Have good starts:
 Both of the criteria are met with  Extrapolated volume less than
analysis of additional acceptable 5% of FVC or 0.15 L,
spirograms; OR whichever is greater; OR

7
Pulmonary Function Testing Riham
Raafat

 A total of eight tests have been  Time-to-PEF of less than 120

performed; OR mins (optional until further
 The patient/subject cannot or information is available)
should not continue . Have a satisfactory exhalation:
.Save at a minimum the three best  6s of exhalation and/or a
maneuvers plateau in the volume-time
curve; OR
 Reasonable duration or a
plateau in the volume-time
curve; OR
 If the subject cannot or should
not continue to exhale

-Derived indices measured: (volume-time curve)

1. Forced vital capacity (FVC):

 It's the maximum volume of air which is expired with greatest
force and spread after maximal inspiration to total lung capacity.
 Normal value: 4800 cc in adult person.
 Measured by volume or flow types of spirometry by the previous
technique or directly from computerized devices as Morgan.

8
Pulmonary Function Testing Riham
Raafat

 Timed FVC: bedside test: patient takes forced inspiration followed

by forced expiration while stethoscope on trachea N. timing 3-4s
 Significance: it decreases in:
o Obstructive airway diseases (COPD, BA, Bronchiectasis, CF)
o Large airway obstruction (F.B. or tumor)
o Pleural, chest wall and muscular abnormalities (low muscle
strength or low diaphragmatic motility with pain, large abdominal
contour, lying, chest deformities)

2. Forced expiratory volume in 1st second:

 It's the maximum volume of air expired by greatest force and
speed after maximum inspiration to TLC at unit time.
 Normal value: in 1st second = 75-85% (FEV2 = 95%, FEV3=97%).
 Measured by the same methods as FVC, and is measure during
ATPS (ambient temperature pressure saturation) with water vapor
then converted to body TPS.
 Significance: differentiate obstructive from restrictive airway
diseases, used also in reversibility testing and pre-operative
assessment.

3. FEV1/FVC: see interpretation.

4. FEF25-75 (maximal mid expiratory flow):

 It's the slope of the spirogram between the 25th and the 75th
percentile of an FVC maneuver. The closing volume from a single-
breath N2 test and frequency-dependent dynamic lung compliance
also can be used to detect small airway disease.
 Normal value: 4-5 L/s (decrease with age).
 Measured by the same methods like FVC.

9
Pulmonary Function Testing Riham
Raafat

 Significance: measures average flow rate in a given interval (seg.),

indicated status of medium sized and small airways, and can also
decrease in moderate to severe restrictive lung diseases when
affecting cross-sectional area of the small airways.

5. MVV (MBC):
 It's the maximum volume of air which can be respired in 1min. by
deepest and fastest breathing (test of entire respiratory system).
 Normal value: male: 80-200 L/min, female: 60-160 L/min.
 Measured by: breathing deeply and rapidly for 15 sec. (to prevent
wash of Co2 with hyperventilation which leads to respiratory
depression, and to decrease effort done by the patient leading to
muscle fatigue) in a bag or spirometer then measuring the volume
of the collected air in Douglas bag by gas meter and multiply by 4;
can also be measured by FEV1 x 35
 Significance:
o Index for respiratory efficiency and physical fitness (better
than VC because it's always abnormal with lung diseases
except in some restrictive diseases when the limitation of
expansion isn't interfering with flow as the patient will
compensate with low TV).
o Help in estimating level of ventilation that can be expected
during exercise  MVV <60 with moderate to severe
obstruction will have ventilation limitation in exercise.
o Respiratory muscle assessment.
o Pre-operative assessment.
o It decreases with age, muscle affection, center affection,
airway resistance or obstruction (if decreases with normal
FEV1 suspect UAO) and low compliance.

10
Pulmonary Function Testing Riham
Raafat

6. PEF: (bed side test)

 It's the maximum flow rate over the first ten milliseconds of forced
expiration (first part of FEV1).
 Normal value: 10 L/s (600 L/min) in healthy adult. (diurnal
variation is normally detected being lowest in the early morning
due to variations in airway caliber).
 Measured by: Wright PEF meter, simple portable devices (measure
up to 300 L/min, but it's small, inexpensive, useful to follow gross
changes in AW function and bedside assessment) and other
methods by drawing a tangent to the steepest part of volume time
spirogram in manner similar to FEF25-75.
 Significance:
o Diagnosis of BA  variability >15-20 % in PEFR in a single
day or from day to day is diagnostic.
o Response to treatment in BA
o Diagnosis of occupational asthma (see occupational), and
exercise induced asthma (fall of FEV1 >15%)

7. Flow-Volume loop:
 It's a curve representing the relation between flow rates and
volume during VC divided into maximum expiratory (from TLC to
RV, not effort dependant) and inspiratory (from RV to TLC, effort
dependant) flow volume curves.
 Normally: FEF50/FIF50 = 0.8
 Measured by: patient must breathe several breaths in tidal
breathing  maximum inspiration to TLC  maximum expiration
to RV  maximum inspiration again.

11
Pulmonary Function Testing Riham
Raafat

 Significance:
o Obtain data: FVC (from TLC to RV), PEFR (from zero line
to maximum expiratory deflection on flow axis), PIFR (-ve
deflection), Timed FEV (if timing or computer are available)
and Maximal Flow Rates at any % volume of air.
o Differentiate between obstructive (volume dependant airway
narrowing) & restrictive (pressure dependant airway
collapse) lesions.
o Localizes site of obstruction (see interpretation).
o Detection of small airway obstruction (specially when other
PFT are normal): use low density gas spirometry comparing
MEFV of 80% O2 & 20% He  MEFV (Vmax 25, 50, 75%)
will be < with a mixture curve than that with room air curve.

N.B The volume-time tracing is most useful in assessing whether the end-of-test
criteria have been met, whereas the flow-volume loop is most valuable in evaluating
the start-of-test criteria. The zero time point on the volume-time tracing has been
carefully defined and extrapolated to provide a uniform start point for measurement. It
corrects for a possible delayed start that may not actually reflect airflow.

12
Pulmonary Function Testing Riham
Raafat

-Interpretation:
 1st must assess test quality (see before)

 Disproportionate reduction in the FEV1 as compared to the FVC

(and therefore the FEV1/FVC ratio) is the hallmark of obstructive
lung diseases. The mechanism responsible for the reduction in
airflow can be bronchial spasm, airway inflammation, increased
intraluminal secretions, and/or reduction in parenchymal support of
the airways due to loss of lung elastic recoil. (GOLD threshold of fixed
FEV1/FVC lacks scientific basis and results in misclassifying patients at either
end of the age spectrum  young can be obstructed and considered normal
and vice versa for an old patient).

 Assessment of reversibility of airway obstruction: When airway

obstruction is identified on spirometry, assessing response to
inhaled BDs is useful. The ATS has recommended that the
threshold for significant response be demonstration of an increase
of at least 12% and 0.2 L in either FVC or FEV1 on a spirogram
performed 10-15 mins after inhalation of a therapeutic dose of a
bronchodilating agent. (New standards recommend the use of 4 inhalations
(100 mcg each, 400 mcg total dose) of albuterol administered through a valved
spacer device. When concern about tremor or heart rate exists, lower doses
may be used. Response to an anticholinergic drug may be assessed 30 mins
after 4 inhalations (40 mcg each, 160 mcg total dose) of ipratropium bromide.
Failure to respond to bronchodilator challenge does not preclude clinical
benefit from bronchodilators. A positive response to the bronchodilators may
correlate with response to steroid therapy).

 Reduction in the FVC with a normal or elevated FEV1/FVC ratio

should trigger further diagnostic workup to rule out restrictive lung
disease. Because the FEV1 is a fraction of the FVC, it also is

13
Pulmonary Function Testing Riham
Raafat

reduced, but the FEV1/FVC ratio is preserved at a normal or

elevated level. Measuring the TLC and residual volume (RV) can
confirm restriction suggested by spirometry.

 The severity of reductions in the FVC and/or the FEV1 can be

characterized by the following scheme:
o Mild - 70-79% of predicted
o Moderate - 60-69% of predicted
o Moderately severe - 50-59%
o Severe - 35-49% of predicted
o Very severe - Less than 35% of predicted
Restrictions caused by: Obstruction caused by:
 Obesity  COPD
 Pregnancy  BA
 Ascitis  Bronchiolitis
 ILD  Pneumonia
 Kyphoscoliosis  Bronchiectasis
 Pleural effusion  Cystic fibrosis
 Pleural tumors  Acute bronchitis
 NM disease  Alpha1 anti-trypsin def.
 Diaphragmatic abnormality
 Lung resection
 Congestive heart failure
 Inability to breathe (pain)
 Severe obstructive disorders
 Cardiomegally

The lower limit of normal is defined as the result of the mean predicted value
(based on the patient's sex, age, and height) minus 1.64 times the standard error of
the estimate from the population study on which the reference equation is based. If
the lower limit of normal is not available, the FVC and FEV1 should be greater
than or equal to 80% of predicted, and the FEV1/FVC ratio should be no more
than 8-9 absolute percentage points below the predicted ratio. The ATS has
recommended the use of lower limits of normal instead of the 80% of predicted
for setting the threshold that defines abnormal test results.
 Note that small airway obstruction may be present even when the
FEV1/FVC is above the lower limit of normal. The mid-flow rate

14
Pulmonary Function Testing Riham
Raafat

or forced expiratory flow occurring in the middle 50% of the

patient's exhaled volume (FEF25-75%) may fall below its lower limit
of normal even when the FVC, FEV1, & FEV1/FVC are all normal.
The lower limit of normal for the FEF25-75% can be < 50% of the
mean predicted value, making it important to use the lower limit of
normal defined by the 95% confidence limit of the mean predicted
value rather than a threshold defined by a fixed percentage of the
predicted value. The FEF25-75% is also very dependent on expiratory
time. If expiratory times of spirometry efforts vary by > 10%,
comparisons of the FEF25-75% before and after BD challenge are
difficult to interpret. Early termination of expiration shifts the
middle 50% of the exhaled volume toward the start of the
exhalation, artifactually raising the FEF25-75%.
 Sitting versus supine vital capacity measurements to evaluate
diaphragmatic strength  reduction in the VC < 90% of the
upright VC suggests diaphragm weakness or paralysis. Interpreting
an increased reduction in VC in the supine position as diaphragm
dysfunction should be made cautiously if the patient's BMI > 45
kg/m2.

 Fixed (as goiters, endotracheal neoplasms, stenosis of both main bronchi,
postintubation stenosis, and performance of the test through a tracheostomy
tube or other fixed orifice device) and variable intrathoracic (as localized
tumors of the lower trachea or mainstem bronchus, tracheomalacia, and airway
changes associated with polychondritis) or extrathoracic (as unilateral and
bilateral vocal cord paralysis, vocal cord adhesions, vocal cord constriction,
laryngeal edema, and upper airway narrowing associated with obstructive
sleep apnea) airway obstructions are differentiated by flow-volume

loop as follows:

15
Pulmonary Function Testing Riham
Raafat

Saw toothed pattern

*N.B. Gestalt approach of interpretation: it's a visual comparison between
individual FV curve to normal predicted one (degree of ventilatory
limitation defined to loss of area under normal predicted curve)  25%
mild, 50% moderate, 75% severe.

 Pre-Operative assessment: When FEV1 is >2L or 50% of predicted

 major complications are rare. Operative risk is heavily
dependent on the surgical site, with chest surgery having the
highest risk for postoperative complications, followed by upper and
lower abdominal sites. (Patient-related factors associated with increased
operative risk for pulmonary complications include preexisting pulmonary
disease, cardiovascular disease, pulmonary hypertension, dyspnea upon
exertion, heavy smoking history, respiratory infection, cough (particularly
productive cough), advanced age (>70 y), malnutrition, general debilitation,
obesity, and prolonged surgery). Assessment for lung surgery involves

16
Pulmonary Function Testing Riham
Raafat

prediction of a postoperative FEV1 by using the preoperative FEV1.

In a borderline case, consideration of the contribution of the
remaining portions can be assessed by a perfusion scan. The
relative % of perfusion (Q) of the remaining lung or lung segments
usually is proportional to its contribution to ventilation & can be
used to estimate postoperative function as shown in the following
equation: Postoperative FEV1 = Preoperative FEV1 X Q% of the
remaining lung.
*N.B. The forced expiratory volume in 1sec (FEV1) begins to decrease after age 20.
The annual decline is small at first but accelerates with aging. The forced vital
capacity (FVC) decreases as well, by about 14 to 30 mL/yr in men and 15 to 24 mL/yr
in women. Until age 40, decreases in FEV1 and FVC are thought to result from
changes in body weight and strength rather than from loss of tissue. After age 40,
decreases in FEV1 and FVC are due to aging itself and superimposed cumulative
effects of inflammatory injury from respiratory illness, smoking, and exposure to
oxidant injuries or environmental toxins. For example, cigarette smoking repeatedly
induces inflammatory mediators, humoral protection (elastase and antielastase,
oxidant and antioxidant), neutrophil recruitment, and tissue repair, culminating in
inflammatory lung destruction and airway obstruction.

-Closing Volume and Closing Capacity:

 Definition:
.Volume is the portion of vital capacity that can be expired from the lungs
after closure of airways, while
.Capacity is the total volume of air maintained in the lungs at the onset of
airway closure = closing volume + RV

 Normal value: Volume = 400ml (9% of VC)

Capacity = 400 + 1200 = 1600ml (32% of TLC)
 Factors affecting them:
o Abdominal causes:

17
Pulmonary Function Testing Riham
Raafat

a. High intra-abdominal pressure: obesity, ascitis, pregnancy,

abdominal distension  early closure of airways on higher lung
volumes  increases closing volume.
b. Liver cirrhosis and causes of ascitis: decrease plasma oncotic
pressure  edema fluid around small airways  narrowing 
increase in closing volume.

o Chest causes:
a. Lost elastic recoil: aging and emphysema  early closure too 
increase closing volume; and
b. Narrowed small airways: cigarette smoking, early chronic
bronchitis, BA attacks, and bronchiolitis obliterans 2ry to rheumatic
fever, dusty occupation and organ transplantation.

o Cardiac causes: mitral stenosis and heart failure  increase left

atrial volume  edema around the terminal bronchioles 
narrowing of small airways  early closure  increasing closing
volume.

*N.B. that's why there is bronchitis features with MS which

disappears after valvotomy; also that's why there is asthmatic
component detected in early stages of pulmonary edema.

 Measurement: "single breath nitrogen washing out test":

It measures the distribution of ventilation by analyzing changes in N2
concentration during expiration of vital capacity after single breath of
100% O2  expiration to RV then inspiration of known volume of 100% O2
then expiration slowly with flow rate 0.3-0.5 L/s w/o holding breath then
monitoring of N2 concentration with an analyzer while the spirometer is
measuring volume of expired air  then a curve is drawn (in 7 mins)

18
Pulmonary Function Testing Riham
Raafat

Tracer gas concentration

Abrupt increase in N2 conc. till RV 4
3 Plateau N2 (relative slow
Abrupt N2 change in N2 & O2 conc.)
(alv. Air only)
Increasing N2 conc. 2
1 100% O2 (from anatomical dead space)

Volume of expirates

Phase 4 indicates lung volume at which closure begins and is sensitive

to change in the caliber of small airways.

*N.B. note that the N2 of the old breath is still found in the apices of
the lungs and residual volume (dead space part), while O2 will be
found in the bases of the lungs that's why N2 is increasing later
through out expiration and abruptly increase through phase 4.

 Significance of the test:

o Used to measure:  closing volume (volume of expired air from
the onset of phase 4 to termination of breath), and closing capacity
(CV + RV; when RV = (FEN2/FAN2 – FEN2) x CV).
.FEN2 = expired N2 detected with analyzer or electronic integration of the area
under the curve.
.FAN2 = N2 concentration in the lung at the beginning of inspiration (N2 conc.
in air is 79%).

o Measurement of vital capacity and FRC: underestimates

obstructive diseases (because in this condition there are lung regions that
are very poorly ventilated, and hence, they lose very little of their nitrogen. A
truer estimate in obstructive disease can be obtained if this test is prolonged to
15 to 20 minutes. However, patients then find the test unpleasant).
o Measurement of anatomical dead space: the initial 750ml (phase 1
and 2) which isn't used in analysis of distribution of ventilation.

19
Pulmonary Function Testing Riham
Raafat

o Assessment of distribution of ventilation: by  difference of N2

concentration between 750ml and 1200ml points of expired air
(normally is <1.5 (3% in older), increases with unequal distribution of gases in
inspiration and unequal emptying rate during expiration as in severe
emphysema) or by slope of phase 3 from point 30% of vital capacity

to phase 4 (normally slope is 0.5-1.0 % N2 of lung volume).

*N.B.: small airway function is detected by:

 Closing volume
 Low density He O2 F-V loops
 Dynamic compliance
 FEF25-75
 MEF volume curve

[B] Whole Body Plethysmography:

-Definition: is the measurement of intrathoracic gas volume (TGV) or
FRC, TLC and airway resistance (Raw) (plethusmos is enlargement in Greek,
plethus is fullness and plethora is full). Secondary tests can be performed

during whole-body plethysmography including: spirometry, bronchial

challenge, diffusing capacity for carbon monoxide, single-breath
nitrogen, multiple-breath nitrogen washout, pulmonary compliance, and
occlusion pressure.
*N.B. Takes Advantage of the principle of Boyle's law, which states that the volume
of gas at a constant temperature varies inversely with the pressure applied to it. The
primary advantage of body plethysmography is that it can measure the total volume of
air in the chest; including gas trapped in bullae + can be performed quickly.
Drawbacks include the complexity of the equipment as well as the need for a patient
to sit in a small enclosed space.
-Types: variable pressure type, volume displacement type and flow type.

-Indications:

20
Pulmonary Function Testing Riham
Raafat

 Diagnosis of restrictive lung disease.

 Measurement of lung volumes several times quickly (mainly TLC and
FRC) to distinguish between restrictive and obstructive processes.
 Evaluation of obstructive lung diseases, such as bullous emphysema
and cystic fibrosis that may produce artifactually low results if
measured using other methods.
 Measurement of lung volumes when multiple repeated trials are
required or when the subject is unable to perform multibreath tests.
 Evaluation of resistance to airflow and alveolar pressure.
 Determination of the response to bronchodilators, as reflected in
changes in airway resistance, airway conductance, and TGV.
 Determination of bronchial hyperreactivity in response to
methacholine, histamine, or isocapnic hyperventilation, as reflected in
changes in TGV, airway resistance, and airway conductance.
 Follow-up assessment of the course of disease and response to
treatment.
-Contraindications:
 Mentally confused patients.
 Patients with muscular incoordination.
 Patients with body casts.
 Inability to pant in a smoothly coordinated fashion.
 Patients having conditions that prevent them from entering the
plethysmograph cabinet or adequately performing the required
maneuvers as:
o Claustrophobia, or
o Requiring continuous oxygen therapy that should not be
discontinued, even temporarily, or
o Continuous intravenous infusions with pumps or

21
Pulmonary Function Testing Riham
Raafat

o Other equipment that should not be disconnected, or that might

interfere with pressure changes (e.g., chest tubes, transtracheal
oxygen (O2) catheter, or ruptured eardrum).

-Technique:
.Patient's preparation:

a. No smoking for at least 1 hour before testing. The time of the last
smoking event should be recorded.
b. The test should be performed at least 1 hour after eating and
physical activity (to avoid bronchospasm).
c. Supplemental O2 and pumping intravenous infusions should be
discontinued before entering the plethysmograph.
d. If pre- and post-bronchodilator testing is to be performed, the
patient should avoid using bronchodilators prior to testing, using
the same schedule as for spirometry.
e. Assessment of patients: for physical and developmental status to
detect ability to perform the test.
f. Postponement may be necessary if the patient has not met the
preparation criteria.

.Technique: (5 mins test)

1. The subject is enclosed in a chamber equipped to measure pressure,
flow, and volume changes; good instructions are given to the patient.
2. Patient sits or stands inside an airtight chamber with unknown
volume of gas in his thorax (FRC (Vf)).
3. Pressure and volume of gas inside the box are measured (Pb, V1).
4. Pressure in the patient's mouth is measured by 2nd manometer (Pb).

22
Pulmonary Function Testing Riham
Raafat

5. Patient exhales all the gas then inhales (small 100ml/pant, quick 1.5-
2.5 b/s and uniform panting) to a particular volume and pressure
(plotted Ppleth/flow).
6. A shutter then drops across the breathing tube; once two to three
acceptable open-shutter loops have been collected, close the mouth
shutter (2 seconds) and instruct the patient to continue panting
(plotted Palv/Ppleth).
7. The patient makes respiratory efforts against the closed shutter,
causing chest volume to expand and decompressing the air in the
lungs.
8. The increase in chest volume slightly reduces the box’s volume
(ΔV), thus slightly increasing the pressure in the box with slight
increase in alveolar pressure (ΔP) (omitted as it's v. small 20 cmH2O
compared to Pb which is 1000).
9. Repeat open- and closed-shutter panting maneuvers until four or five
technically acceptable tests are obtained.
[Link] result by: Pb Vf = (Pb+ ΔP)(Vf - ΔV), so Vf = ΔV/ ΔP (Pb
-ΔP) as Boyle's law (PV of a gas is constant with constant isothermal
temperature) and resistance measured by Ohm's law = P/flow (see later).

.Equipment quality control:

 Regular documentation.
 Calibration at recommended frequencies, at any time accuracy is
suspect, and when the equipment is moved to a different location.
1. On a daily basis, calibrate volume, mouth and box pressure (by 3L
syringe; 0-1.5 L/s with rotameter).
2. At least monthly, manually calibrate systems in addition to daily use
of the auto calibration system.
3. At least weekly, assess linearity of flow-sensing device.

23
Pulmonary Function Testing Riham
Raafat

4. At least quarterly, perform airway resistance with a known resistor

and calculate results.
5. At least annually or at a frequency established by the laboratory on
the basis of the tendency of the device to vary, check volume with
isothermal bottle.
6. At least monthly and at any time accuracy is suspect, perform tests
on standard subjects (biologic controls, or bio-QC).
7. Test standard subjects more frequently initially to establish statistical
variation for comparison.
8. It may be advantageous to perform Bio-QC at weekly or semi-
monthly intervals.
 Test Quality Assessment: Results are valid if the equipment functions
correctly and the subject is able to perform acceptable and reproducible
maneuvers.
 Reference Equations are available for each laboratory.
 Transducers in the plethysmograph should meet prescribed range
specifications:
Mouth pressure: ±20 to 50 cm H2O
Box pressure: ±2 cm H2O (500-L box)
Flow: 0.2 to 1.5 L/s

-Derived indices measured:

1. RV:
 It's the air remaining in the lungs after complete maximum forced
expiration.
 Normal value: 1.5 liters.
 Measurement: RV= FRC-ERV
 Significance:
o Determine whether it's obstruction (high) or restriction (low).

24
Pulmonary Function Testing Riham
Raafat

o In mixed pattern (as lung resection)  low RV, TLC, high ratio
o NM disorders  low RV, TLC, high or normal ratio

2. FRC:
 It's the volume of air remaining in the lungs after normal expiration (it
maintains gas exchange in between breathes and renew RV) or it's the
volume when inward elastic force of the lung = outward elastic forces
of chest wall.
 Normal value: 2200 cc (40-50% of TLC).
 Measured by: nitrogen washout method, inert gas dilution,
plethysmography and by measuring TLC by radiographic methods.
 Significance: high in emphysema (decrease elastic recoil of the lung),
low with fibrosis (increase elastic recoil of the lung) and supine
position (lack of gravity effect of abdominal viscera).

3. TLC:
 It's SVC + RV
 Normal value: 6 liters.
 Significance: as RV.

[C] Gas Dilution Method:

-Definition: method used to measure RV and FRC.

-Techniques:
A. Manual: patient expires deeply and inhales (3-4 times) in a bag
with a known volume of inert gas (Helium) which is insoluble in
blood  mixed with RV  measure expired He in the bag with
He analyzer  dilution formula to detect RV (RV = volume of
He used / volume of He in expired air).

25
Pulmonary Function Testing Riham
Raafat

B. Closed circuit: by suitable spirometer filled with known volume

of gas (V1) (600ml of He) with 10% conc. (C1)  patient
connected to closed circuit with known conc. and volume of He
 rebreathing the gas in spirometer (with CO2 absorber placed
with the spirometer) till the conc. of He decreases to a stable level
(equilibrium) in < 7 mins then O2 is added to the spirometer
system to maintain the fractional conc. at a level near or above
that of room air and to keep the system volume relatively
constant  after equilibrium the final conc. (C2) of He is
recorded by an analyzer  FVC = C1 x V1 = C2 [V1 + V2] 
(when V2 = FRC)  it underestimates obstructive diseases.
C. Open circuit: "N2 washing out method" (see before)

[D] Broncho-Provocation tests:

-Definition: Tests used to detect airway hyperreactivity to certain
pharmacological or environmental agents (done in specialized centers).

-Agents used: (taken with nebulizers)

 Pharmacological  Methacholine, Histamine, Carbocholine.
 Specific agents: inhaling agents as house dust, pollens or mites.
 Exercise induced agents: cold air challenge, dry air challenge, and
isocapnic hyperventilation.

-Indications:

.Indications for methacholine challenge test:

1. The primary indication is to exclude (rule out) a diagnosis of
asthma in those individuals with symptoms that suggest asthma (e.g.,
cough, wheezing or chest tightness following exposure to cold air, just

26
Pulmonary Function Testing Riham
Raafat

after exercise, or during respiratory infections)  it has better –ve

predictive power than a +ve one.
[Link] potential indications include: establishing a diagnosis of
asthma, determining the relative risk of a healthy individual
developing asthma, assessing the severity of asthma, and assessing the
response to therapeutic interventions.

.Indications of Exercise challenge test:

1. The presence of or changes in EIB
2. The severity of the airway response to exercise
3. The effectiveness of acute or chronic medication or other
therapeutic modalities in the prevention of EIB

-Contraindications:
ECT MCT
Absolute: Absolute:
[Link] complicated MI, PE 1. Moderate to severe airway
[Link] in the resting ECG that obstruction, or FEV1 <1.0 L in
suggest an acute or recent adults.
myocardial event 2. Recent MI or cerebral vascular
[Link] angina, acute BA accident (within 3 months).
[Link] cardiac arrhythmia 3. Known arterial aneurysm.
5. Severe AS or known or [Link] HTN (>200/100)
suspected dissecting aortic
aneurysm.
6. Active or suspected acute
pericarditis or myocarditis.
[Link] congestive heart failure
[Link] febrile illness

27
Pulmonary Function Testing Riham
Raafat

Relative: Relative:
1. Moderate to severe airflow [Link] to moderate airways obst.,
obstruction at baseline FEV1<1.5 L or FEV1 <1.5 L in adults
or FEV1 <70% of predicted. [Link] to perform PFTs or poor
[Link] systemic HTN (>200/120) reproducibility on PFTs (e.g.FEV1)
[Link] tachycardia (>120 min) [Link] or breast feeding
[Link] PVCs, PACs [Link] use of cholinesterase-
[Link] aortic stenosis inhibitor medication
[Link] valvular heart disease *If any of these factors are present, the
Or cardiomyopathy. technician should discuss the issue with
[Link] electrolyte abnormalities the ordering physician or laboratory
(hypokalemia & hypomagnesemia) medical director.
[Link] diabetes
9. Orthopedic or other limitations
to exercise (as complicated or
advanced pregnancy)
10. Current or recent respiratory
tract infection.
*Other variables that could affect the

diagnostic value of the procedure include:

.Intake of xanthine-containing products

(e.g., coffee, cola, and chocolate)

.Vigorous exercise within 4 hours before

the test (may produce false -ve result)

.Recent use of certain medications

-Technique:

28
Pulmonary Function Testing Riham
Raafat

ECT MCT
.Patient's preparation: .Patient's preparation:
-Wear suitable clothes and shoes -Prevent drug affecting AW
for exercise. caliber:
-Prevent drugs affecting airway B2 long acting  48 hrs before.
B2 short acting  6 hrs before.
caliber as in MCT.
Anticholinergics  48 hrs before.
-Coffee, tea, cola, chocolate and Theophyllines  8-48 hrs before.
Cromolyns  8- 48 hrs before.
smoking stopped 3 hrs before the
Leukotrien modifiers  24 hrs.
test. GCS  on the day of test.
Antihistaminic  48hrs-5ds
-Consent is signed.
before.
-Spirometry or PEFR or Raw is
- Coffee, Tea, Cola Drinks,
done prior and after test.
Chocolate, & Smoking are
stopped on the day.
.Devices used:
- Consent including all details.
-The preferred modes of exercise
are the motor-driven treadmill .Technique and doses:
with adjustable speed (0-8mph) &
Hygroscopic metacholine is put in
grade (0-20%) or the
electromagnetically braked cycle a diluent (normal saline with
ergometer for 6-8 mins. preservative as 0.4% phenol or 1.5%
-Heart rate should be monitored
from a 3-lead ECG configuration benzyl alcohol)  e.g to form 4 ml
as a minimum or pulse oximeter or of 25 mg/ml sol. Combine 100ml
other device able to reliably
determine heart rate may be used. to 4 ml diluent
(For those at higher risk for coronary
artery disease or CPX, a 12-lead ECG
 Stored solution in 4 degree
configuration is advisable). (shave, clean) temp. (stable for 15 wk) 
-The patient inspires dry air <
25°C with a nose clip in place, as nebulization of diluent first then
nasal breathing decreases the equilibrated (in room air for 30
water loss from the airways. (This
can be accomplished by: conducting the mins pretest) methacholine (starting
study in an air-conditioned room (with dose depends on: if FEV1 >80 with fall
ambient temperature of 20-25'C) with
low relative humidity (50% or less) or 10% with diluent with no BD can start
through a mouthpiece and a two-way

29
Pulmonary Function Testing Riham
Raafat
breathing valve or dry inhalate is with 1-2mg/ml, if took BD start with
obtained by filling talc-free
meteorological balloons with gas from a 0.25 mg/ml, if took GCS start with
medical-grade compressed air source or 0.125, if child start with 0.03)  PFT
can be inspired through a demand valve
attached to the inspired port of the two- is done after each dose in 1-2 mins
way valve, although this provides some
extra inspiratory resistance at high flow and not for more than 5 mins 
rates).
*provocation dose is the dose of agent
.Response: which causes drop in index's baseline of

The presence of exercise-induced bronchial hyperactivity. FEV1 actively

or Raw (body box or IOS) passively or
bronchoconstriction is defined by
specific conductance used as indices.
plotting FEV, as a percentage of
 Decrease 20% in FEV1 or
the preexercise baseline FEV, at
increase 40% in sRaw is
each post exercise interval. A
significant. (prepare BD if </=
decrease <90% of the baseline
80% FEV1)
FEV, (i.e. a 10% or 15% decrease)
is a generally accepted abnormal highest post-diluent FEV1 -

response (usually after 10 mins highest post-methacholine

exercise). FEV1
% change =
x100
highest post-diluent FEV1

.Precautions:
Ready by epinephrine & other
BDs for possibility of acute severe
BA.

[E] Gas Diffusion tests (DLCo):

-Definition:
The amount of gas transferred across the alveolo-capillary membrane per
minute per mmHg of driving pressure of the gas = (Vgas/P1-P2)  when
P1 is pressure of the gas in alveoli and P2 is pressure of the gas in blood

30
Pulmonary Function Testing Riham
Raafat

(diffusion has two components: transfer of gas from alveoli to RBCs then
combination of gas with Hb)

-Normal value: (decrease with age, in females and increase in exercise,

supine position (inc. perfusion to apex so correct physiological V/Q mismatch))
 Co diffusing capacity  25-30 ml/min/mmHg (P2 is small so it's
neglected).
 O2 diffusing capacity  Co DC x 1.32 = 15ml/min/mmHg  increase
to 65 with exercise due to increased vascular supply (VD and number
inc.), expansion of alveoli and increase pressure gradient.
 Co2 diffusing capacity  400 ml/min/mmHg.

-Types of tests: Co is used due to: great affinity to Hb (240 times O2)
and relatively large difference between [Link] and [Link] so it's more
accurate and reproducible than O2.
 Single breath method (studied in details)
 Multiple breath method (for children and ill to avoid holding breath)
 Re-breathing method (smaller Co load, 30 b/m)
 Steady state method (breath in gas container and expire till steady state)
 Fractional gas uptake method

-Indications:

[Link] and follow-up of diseases which involve lung parenchyma.

[Link] and follow-up of emphysema.
[Link] among chronic bronchitis, emphysema, and asthma.
[Link] of pulmonary involvement in systemic diseases.
[Link] of cardiovascular diseases.
[Link] of arterial desaturation during exercise in some patients with
lung disease.

31
Pulmonary Function Testing Riham
Raafat

[Link] and quantification of impairment and disability associated

with interstitial lung diseases and emphysema.
[Link] of the pulmonary effects of chemotherapy agents or other
drugs known to induce pulmonary dysfunction.
[Link] of pulmonary hemorrhage (artificial uptake of Co by blood
giving a false +ve result).
10. As an early indication of certain pulmonary infections that cause
diffuse pneumocystis (e.g., pneumocystis pneumonia).

-Contraindications:

1. Mental confusion or muscular incoordination that prevents the patient

from adequately performing the maneuver or inability to obtain an
adequate lip seal on the instrument mouthpiece.
2. A large meal or vigorous exercise immediately before test.

-Factors influencing diffusion:

[DLCo = (Vg x Diffusion co-efficient (solubility/molecular weight of
gas) x Surface Area) / Thickness of alveolo-capillary membrane (N=0.2-
0.5mcm)] and [1/DC = 1/DM (membrane resistance, conductivity) + 1/ Vc

(CO–Hb chemical reaction rate; Vc: volume of pulmonary capillary blood)]

 Extrapulmonary reduction in lung inflation (reduced alveolar volume)

producing changes in DM or Vc that reduce DLCO:
o Reduced effort or respiratory muscle weakness
o Thoracic deformity preventing full inflation
 Diseases that reduce Vc and thus reduce DLCO:
o Anemia (corrected DLCO = uncorrected DLCO x [10.22 (in
males) or 9.38 (in females) +Hb]/ [1.7xHb]).
o Pulmonary emboli
 Other conditions that reduce Vc and thus reduce DLCO:

32
Pulmonary Function Testing Riham
Raafat

o Hb binding changes (e.g. HbCO, increased FIO2)

o Valsalva maneuver (increased intrathoracic pressure)
 Diseases reduce (in varying degrees) DM & Vc & so reduce DLCO:
o Lung resection (compensatory recruitment of Vc exists)
o Emphysema
o Interstitial lung disease (e.g. IPF, sarcoidosis)
o Pulmonary edema
o Pulmonary vasculitis
o Pulmonary hypertension
 Diseases that increase Vc and thus increase DLCO:
o Polycythemia (inc. red cell mass  inc. S.A.).
o Left-to-right shunt.
o Pulmonary hemorrhage (not strictly an increase in Vc, but
effectively an increase in lung Hb).
o Asthma
 Other conditions that increase Vc and thus increase DLCO:
o Hb binding changes (e.g. reduced FIO2)
o Muller maneuver (inspiratory effort against closed airway)
(decreased ITP as in asthma, resistance breathing)
o Exercise (in addition, a possible DM component)
o Supine position (possibly a slight increase also in DM)
o Obesity (in addition, a possible DM component)
o High altitudes (with high PO2).

-Technique: (of single breath method)

.Patient's Preparation:
a. Stop smoking for 24 hours before the test.

b. Avoid alcohol for at least 4 hours before testing (15% less in 90 mins).

33
Pulmonary Function Testing Riham
Raafat

c. The test should be performed at least 2 hours after eating and with the
patient having refrained from recent strenuous exercise.
d. The patient should be seated for at least 5 minutes before testing and
remain seated throughout the procedure.
e. Supplemental O2 should be discontinued at least 5 minutes before
beginning the test. If this cannot be done safely, the interval of time
off O2 should be adjusted appropriately and recorded, and the results
interpreted with caution.
f. Assessment of patients for physical and developmental status to
determine ability to perform the diagnostic test.
g. Mention if menstruating (13% change in results with menstrual cycle).

.Technique:
Patient takes maximum inspiration of a mixture of 21% O2 + 10% He +
0.3% Co in N2 then hold breath for 10 seconds followed by smooth full
expiration  sample is taken and analyzed for Co and He.

.Acceptable test criteria:

a. Use of proper quality-controlled equipment.
b. Inspired volume of >85% of largest VC in 4s.
c. A stable calculated breath hold for 10 ± 2s. There should be no
evidence of leaks, or Valsalva or Mueller maneuvers.
d. Expiration in 4s (and sample collection time 3s), with appropriate
clearance of dead space and proper sampling/analysis of alveolar
gas.

.Equipment quality control

1. Gas-analyzer zeroing: Done before/after each test.
2. Volume accuracy: Tested daily.
3. Standard subject or simulator testing: Tested at least weekly.

34
Pulmonary Function Testing Riham
Raafat

4. Gas-analyzer linearity: Tested every 3 months.

5. Timer: Tested every 3 months.

-Interpretation: (predicted values are dependent on age, stature and sex).

Mild: >60% and <LLN (lower limit of normal)
Moderate: 40–60%
Severe: <40% of predicted values
FEV1/VC
Normal Low

VC VC

Lo Low
Normal
w

Normal TLC TLC

Normal or high
Low Normal Low
or high

Spirometry Restriction Obstruction Obstructive &

Normal Restrictive Defects

DLCO DLCO DLCO DLCO

Normal Normal Normal

Low Low Low Normal
or high or high or high
or high Low

Normal PV Chest wall or ILD or Asthma or Emphysema Chest wall,

ILD,
Disorder Neuromuscular Pneumonitis Chronic Neuromuscular
Pneumonitis,
Disorders Bronchitis Disorders,
or
Asthma, or
Emphysema
Chronic
Bronchitis

*N.B. in 1ry pulmonary hypertension: all are normal values and CXR
with striking low DLCO (<50%) & desaturation with exercise can occur.
*N.B. Diffusing capacity peaks in people in their early 20s and then declines; from
middle age onward, it declines at a rate of about 17% (2.03 mL/min/mm Hg) per
decade in men and at a rate of about 15% (1.47 mL/min/mm Hg) per decade in
women. This decline results from decreased alveolar-capillary surface area caused by
inflammation-induced destruction of alveoli and by thickening and inflammation-
induced destruction of capillary-containing alveolar walls. The loss of alveolar-
capillary surface area decreases venous blood oxygenation, particularly under
conditions of high pulmonary blood flow (eg, exercise). The rate of decline in
diffusing capacity among women may be lower because endogenous estrogen may

35
Pulmonary Function Testing Riham
Raafat
slow the destruction of alveolar-capillary tissue in women between ages 25 and 46;
destruction slows presumably because of preserved vascular integrity.

[F] Blood sampling and using gas analyzer (ABGs):

-Indications:
a. Evaluation of the adequacy of a patient's ventilatory status, acid-
base, and/or oxygen (O2) status, intrapulmonary shunt, and O2-
carrying capacity of the blood.
b. Diagnostic evaluation and/or quantification of the response to
therapeutic interventions.
c. Monitoring the severity and progression of a documented disease
process.

-Contraindications:
In the analyzer:
a. An improperly functioning analyzer.
b. An analyzer that has not had the functional status verified by
commercial quality control or tonometered whole blood.
c. A specimen that has not been properly anticoagulated.
d. An inadequately labeled specimen lacking a unique identifier.
e. A specimen containing visible air bubbles.
f. An improperly stored specimen.
g. An incomplete requisition slip that precludes adequate interpretation
and documentation of results.

In the Patient:
h. A negative Allen test for a radial puncture site.
i. Performance of a puncture through a lesion or through or distal to a
surgical shunt.

36
Pulmonary Function Testing Riham
Raafat

j. Coagulapathy or medium-to-high-dose anticoagulation therapy

(relative).

-Precautions of Arterial Puncture:

[Link].
[Link] syncopal reactions manifested by: pallor, peripheral
cyanosis, hypotension, nausea, cold-clammy sweating, syncope, and
bradycardia.
[Link] formation.
[Link] thrombosis and embolism.
[Link] to a vessel or nerve.
[Link].
[Link] reaction from local anesthetic, if applicable, and/or antiseptic
solution.
[Link].
[Link] occlusion.
[Link].

-Technique:
 The site of preference is the radial artery  the brachial artery is the
next choice. The radial artery site should not be used if:
a. The modified Allen test demonstrates poor ulnar blood flow:
(Ask patient to close fist tightly to force most of the blood from the hand. Apply

pressure at wrist to compress and obstruct radial and ulnar arteries. Ask patient to

unclench fist and remove pressure from only the ulnar artery. Observe the inside

of the palm for flushing of palm, fingers, and thumb for 10 seconds. Flushing

within 10 seconds indicates a positive modified Allen test. Negative results must

prompt assessment of alternative sites  can't be performed in: unconscious

37
Pulmonary Function Testing Riham
Raafat

patients or those with wrist or palm burns and patients in shock, deeply jaundiced,

or when there is a problem with evaluation of reperfusion).

b. Inaccessibility due to dressings, casts, and IV lines; hematomas or
laceration of tissue due to multiple radial punctures.
c. Inability to adequately palpate the vessel.
d. Patient statement of previous difficulties with radial puncture s.
 Put 0.1 ml of sodium heparin solution into the syringe or use
preheparinized syringes (100 USP units of lyphilized lithium heparin).
 Assess the patient and put antiseptic solution (alcohol or iodine) on the
puncture area
 Puncture technique:
a. Hyper-extend the patient's wrist or elbow (according to puncture
site) to approximately 45° and support it if needed.
b. Locate the exact puncture site by palpating the artery with the
fingers of one hand.
c. While continuing to palpate the pulse with one hand, use the other
hand to slowly advance the needle with the bevel up, piercing the
skin at an angle of 45-60° toward the palpable pulsation.
d. Penetration of the artery may be sensed by feel or by observing
spontaneous filling of the syringe dead space with arterial blood.
e. Withdraw the syringe and needle quickly after the required amount
of blood has been obtained (not <0.5ml). Immediately place dry
gauze over the puncture site & compress the site for at least 5 mins.
f. Transfer the sample in an ice-water.

-Interpretation:
Normal Critical

PH 7.35 to 7.45 <7.20 or >7.60

PaCO2 36 to 44 mmHg >65 mmHg

38
Pulmonary Function Testing Riham
Raafat

PaO2 >70 mmHg^ <50 mmHg

^Altitude and age specific
*N.B: Partial pressure of arterial oxygen (PaO2) declines linearly with aging (about
0.3%/yr) until age 75, at which time it stabilizes at about 80 mm Hg in healthy
nonsmokers. This gradual decline is mostly attributable to ventilation/perfusion (V/Q)
mismatch caused by age-related collapse of peripheral airways, leading to shunting of
blood through nonventilated alveoli. PaO2 at any age can be roughly estimated by the
equation PaO2 = 109 - (0.43 x age).

[G] Oximetry for O2 saturation:

-Definition:

Pulse oximetry provides an estimate of arterial oxyhemoglobin saturation

(SaO2) using selected wavelengths of light to non-invasively determine
the saturation of oxyhemoglobin (SpO2). (Hemoglobin species absorb
wavelengths in the visible and infrared spectrum (between 600 and 1000 nm). The

amount of light absorption at each light frequency depends on the degree of

oxygenation within the tissues. Oxyhemoglobin absorbs less light in the 600 nm

region than nonoxygenated or reduced hemoglobin (deoxyhemoglobin). By

comparing the light absorption of the two wavelengths of light during a heart beat, the
ratio of oxyhemoglobin to deoxyhemoglobin can be used to estimate arterial O2

saturation).

-Type of Probes:
1. Transmittance probes are the most common type and are placed
over a pulsating area such as a finger, toe, or earlobe  contain
light-emitting diodes (LEDs) on one side and a photo detector on
the other side.
2. Reflectance probes have the light source and photo detector placed
on the same side of a pulsating area  placed on the forehead or
on the temple with double-sided adhesive.

39
Pulmonary Function Testing Riham
Raafat

-Indications:
1. Assess and quantify the adequacy of SaO2 at rest and during exercise
in patients who are clinically suspected of desaturation [e.g., dyspnea on
exertion, pulmonary disease, decreased DLCO, decreased PaO2 at rest].
2. Abnormal diagnostic test results [e.g., ABGs, DLCO, and FEV1].
3. Titrate or adjust supplemental O2 to treat hypoxemia or desaturation
during activity.
4. Assess preoperatively.
5. Assess the degree of impairment for medico-legal disability evaluation
(e.g., pneumoconiosis, or asbestosis).
6. Evaluate the effectiveness of a therapeutic intervention.
7. Ensure that oxygenation is maintained during anesthesia or operative
procedures.

[H] Capnography for trans-cutaneous CO2:

-Phase I: Functional dead space without CO2:

40
Pulmonary Function Testing Riham
Raafat
With beginning expiration the normal Capnogram shows few or no CO2; the air
portion from the dead space which did not participate in the gas exchange

-Phase II: mixed air phase with steeply increasing CO2-concentration:

The air is expired from both the airways and the alveoli.
-Phase III: Alveolar plateau with a small increase of the CO2-concentration:
The alveolar gas kept its balance with the capillary blood gases; on optimum
conditions alveolar and arterial CO2-concentrations are comparable.
-Phase IV: "Closing-Volume" including an increase of the CO2-concentration:
At maximum expiration, an occlusion of the terminal alveoli occurs, whereas the
apical, better ventilated areas of the lung continue to deliver their higher CO 2-
concentration.  Elevated results in obstructive ventilatory abnormalities

[I] Lung Compliance tests:

-Definition:
 Compliance is defined as the change in volume divided by the change
in pressure  a measure of the lung's elasticity.
 Compliance of the lungs (CL) is defined as the change in lung volume
resulting from a change of 1cmH2O in the elastic pressure
[Transpulmonary pressure = Palv (=Patm at rest or FRC)-Ppl  if
airflow is intact (CLdyn)] or [Ppl  if no airflow (CLstat)] of the lung.
 Compliance of the chest wall (Ccw) is the change in thoracic volume
per unit change in intrathoracic pressure (0.2 L/cmH2O).
 When the lung is not moving (that is, airflow is zero), the Ppl is
negative (subatmospheric -5 cmH2O to keep airways open). The lungs
are elastic and always tend to collapse. This is resisted by the chest
wall, so the Ppl when volume is not changing reflects the static elastic
pressure or recoil of the lung at that volume. If lung volume is
increased by a known amount (Δ of V) and volume is again held
constant, the new Ppl is more negative (the recoil of the lung is
greater). This Δ in V divided by the difference in the two static Ppl

41
Pulmonary Function Testing Riham
Raafat

values (Δ in Ppl) defines the lung compliance, CL = ΔV/ ΔPpl (L/cm

H2O). In addition, it is common practice to measure the elastic recoil
pressure with the subject holding his or her breath at total lung
capacity (TLC); this is termed the PTLC (recoil pressure at TLC).

-Types:
a. Static Compliance:
The test is performed by inserting a very small balloon catheter into the
esophagus, which is used to estimate pleural pressure (the pressure
surrounding the lung). Once this catheter is in place, the patient is asked
to exhale slowly through a mouthpiece and into a device used to measure
volume. The mouthpiece is blocked periodically during exhalation, for a
fraction of a second each time, permitting an estimate of the pressure
across the wall of the lung (static transpulmonary pressure). A graph of
lung volume (measured by spirometry) versus static transpulmonary
pressure produces a curve whose slope is the compliance.

b. Dynamic Compliance:

42
Pulmonary Function Testing Riham
Raafat

During a breath, there are two times when airflow is zero. These occur at
the end of inspiration and the end of expiration. The difference in Ppl at
these two times also defines a change in elastic recoil pressure. This
change in Ppl divided by the volume change is called the dynamic
compliance of the lung (CLdyn).

c. The compliance of the entire respiratory system (Crs):

It requires that the respiratory muscles be relaxed. This measurement is
most often made when a patient is on a ventilator. The patient's lungs are
inflated, the airway is occluded, and the occluded airway pressure is
measured. The lungs are allowed to deflate a measured amount, and a
second occlusion pressure is obtained. Crs is the change in volume
divided by the difference in the two pressures. Because the lungs and
chest wall are in series, Crs includes both lung (CLstat) and chest wall
compliance (Ccw). Because the reciprocals of the compliances are added,
the equation describing this relationship is as follows: 1/Crs = 1/ CLstat +

43
Pulmonary Function Testing Riham
Raafat

1/ Ccw  Thus, a decrease in Crs may be due to a decrease in either lung

or chest wall compliance (or both), a fact that is sometimes overlooked.

-Interpretation:
1. In normal adult subjects, CLstat and CLdyn are nearly the same and
range from 0.150 to 0.250 L/cm H2O. In this group CL varies
directly with lung size, compliance being lower in subjects with
small lungs.

2. Compliance is reduced in subjects with pulmonary fibrosis, often to

values as low as 0.050 L/cm H2O (shift to the right), reflecting the
fact that these lungs are very stiff. Large changes in pressure produce
only small changes in volume. Again, static and dynamic
compliance are similar.

3. The situation in COPD, especially emphysema, is different. Static

compliance is much increased, to values often more than 0.500 L/cm
H2O. This high compliance reflects the floppy, inelastic lungs.
However, CLdyn is much lower, often in the normal range. The
explanation for this apparent paradox relates to the very nonuniform
ventilation of the lungs in COPD. In essence, during breathing in
COPD, air preferentially flows into and out of the more normal
regions of the lung. Because the elasticity of these regions is not as
severely impaired, CLdyn is nearer normal values. This difference
between CLstat and CLdyn is referred to as frequency dependence of
compliance. It is important to remember that a low CLdyn in COPD
does not mean that the lung is stiff or fibrotic.
*N.B: .Beginning at about age 30, there is a decrease in the number and elasticity of
parenchymal elastic fibers, which causes gradual loss of elastic recoil of the lungs
(increasing compliance). Airway size also decreases.

44
Pulmonary Function Testing Riham
Raafat
.At about age 55, respiratory muscles begin to weaken, and the chest wall gradually
becomes stiffer (decreasing compliance). These changes likely result from age-
associated kyphoscoliosis, calcification of intercostal cartilage, and arthritis of the
costovertebral joints. The increased outward pull of the stiffer chest wall combined
with the reduced ability of the lung to pull inward result in a small increase in
functional residual capacity (FRC--i.e., lung volume at the end of a quiet expiration)
and residual volume (RV--i.e., lung volume after a maximal expiration). Total lung
capacity (TLC--i.e., lung volume after maximal inspiration) remains fairly constant.

-Factors affecting compliance:

 Surface tension of alveolar fluid when increases (it's counteracted

physiologically by: elastic tissue of the lung and surfactant) and

Transpulmonary pressure when increases (as in chest wall
diseases, muscular diseases or restrictive lung diseases), decreases
compliance.
 Volume of the lung when increases, increase compliance.
 Expiration increases compliance.

[J] Impulse Oscillometry:

-Definitions:
 Resistance (Rpulm) is the pressure required to produce a flow of 1L/s
into or out of the lung. It's divided into tissue resistance (20%) & airway
resistance (Raw) (70% in large airways & 10% in small airways due to
larger S.A)  N=1-3 cmH2O/L/s (> in children due to smaller lungs).

 Impedance (Z) is the key concept of the forced oscillatory respiratory

mechanics and considered as a generalization to resistance description;
(Z = Zrs,in or R (in-phase component or real part) + reactance (X) (out-of-phase or
imaginary part)  appear as functions of the frequency of oscillation (f). R describes
the dissipative mechanical properties of the respiratory system, whereas X is related to
the energy storage capacity and thus determined jointly by the elastic properties (P/V)
dominant at low oscillation frequencies and the inertive properties (P/V acceleration),
which become progressively more important with increasing f).

45
Pulmonary Function Testing Riham
Raafat

 Flow (F or ύ) in a tube is dependant on the pressure difference between

the two ends of that tube so that ύ = ΔP / R  flow in large airways is
Turbulent (air depends on its density to flow) so that R = ΔP / ύ
according to Ohm's law while flow in small airways is Laminar (air
depends on viscosity to flow) so that R = ΔP / ύ when ύ = 8 η (viscosity
of gas) L / Π r4 according to poisouille's law.

 Conductance (G) is the reciprocal of resistance 1/R (L/s/cmH2O)  if

R increased C decrease so that flow of air isn't conducted well.

-Factors affecting Resistance:

 Radius  if 1/2  R increases 16 fold (inverse proportion)
 Volume of the lung (inverse proportion)
 Gas viscosity (direct proportion)
 Length of airway (direct proportion)
 MEFR or PEF (inverse proportion)  evidenced by low FEV1 and
FEF25-75 with exception in elderly (low FEV1 but normal R) and
extrathoracic obstruction (normal PEF with high R).

-Indications of IOS:

a. Early detection of pathological impairments of the small airways.

b. Early diagnostic capabilities, sp. in premature chronic lung disease.
c. Bronchial reactivity measurement (>50% increase of R or 33%
decrease of G).
d. Pediatric BA assessment.
e. Differentiate between peripheral and central airway disease.
f. The perfect diagnostic tool for pediatric as young as 4yrs, geriatric,
and neurologically compromised patients (needs no effort).
g. Determine the effects of medication in different sites of the lung.

46
Pulmonary Function Testing Riham
Raafat

h. Follow changes in respiratory mechanics during conventional

mechanical ventilation (CMV), respiratory maneuvers & sleep
studies.
i. Used for epidemiological and field studies.

-Disadvantages: can't differentiate between obstructive and restrictive

diseases, nor intra and extra-pulmonary diseases.

-Approaches to measure R:
.Flow at the mouth (central airflow ύao) can be measured with a
flowmeter or pneumatograph attached to the mouthpiece or ETT or
facemask in children.

.Pressures driving the flow are measured by:

1. Pleural pressure (Ppl) can be measured from a small balloon-catheter
unit placed in the lower third of the esophagus and attached to a
pressure transducer. Pressure changes in the esophagus have been
shown to reflect those in the pleural cavity  Rpulm = Ppl-Pao (the
pressure at the mouth which is atmospheric) is the driving pressure / ύ.

2. Alveolar pressure (Palv) and relate this to Pao. Palv can be measured in
a body plethysmograph and does not require swallowing an
esophageal balloon  Raw = Palv-Pao /ύ, Raw is slightly < Rpulm
because of the absence of tissue R.
*N.B.: Both Rpulm and Raw can be measured during either inspiration or
expiration, or as an average of both.

3. Respiratory system Impedance (Zrs) is measured by forced

oscillometry technique (FOT) either single frequency (mainly medium
frequency range 2-4 to 10 Hz with spontaneous breathing, detect rapid
changes as in respiratory cycle and broncho-motor tone changes) or

47
Pulmonary Function Testing Riham
Raafat

composite signals (multi-frequency from 4-30Hz as pseudorandom

noise or recurrent impulses is preferred) = Prs (trans respiratory or Pao
– Patm) / ύao (where Zrs is divided into ZL (lung)= Pao-Pes/ ύao and Zw
(chest wall) =Pes-Pbs/ ύao) (bs is body surface and es is intra-esophageal).

-Interpretation:
In the following diagrams the healthy respiratory system exhibits a
largely frequency independent respiratory resistance (Rrs) whose major
component is airway resistance (Raw)  R5 is the total resistance and R20
is the central resistance & the difference shows the peripheral R ( N <150).
Respiratory reactance (Xrs) undergoes the transition from negative values
(when the elastic reactance dominates) to positive values increasing with
f (the dominance of inertial reactance). At the characteristic resonant
frequency (fres), where Xrs crosses zero, the elastic and inertial forces are
equal in magnitude and opposite (NX5=predicted - 0.20 < best measured).
(The --- indicates airway obstruction with fres shifted to the right  return
to N site if reversibility +ve after BD):

48
Pulmonary Function Testing Riham
Raafat

*N.B. The low-frequency oscillations include the frequencies of

spontaneous breathing and, accordingly, can be applied during apneic
conditions only, whereas the high-frequency range contains oscillations
up to several 100 Hz, which is less affected by tissue properties. Use of
low frequency and high-frequency forced oscillations reveals different
mechanical properties of the respiratory system, and these techniques
have been developed at research level.

-Technique:
[Link] subject is connected via a mouthpiece to the set-up that most
commonly utilizes a loudspeaker to deliver the forced oscillatory
signal. (Patient must be resting before the test for at least 3 mins).
[Link] P and F signals are measured next to the mouthpiece. To enable
spontaneous breathing of the subject, a shunt pathway open to the
atmosphere is necessary; this is usually a wide-bore side tube (with a
high impedance to present a small leak for the high oscillatory
frequencies and a low resistance against spontaneous breathing)
placed in parallel to the loudspeaker. A mechanical resistor may also
be used for this purpose.
c.A bias flow to flush the dead space is optional and can preferably be
introduced between the loudspeaker and the pneumotachygraphy.
[Link] filter can be added for hygienic purposes.
[Link] (3-5 accepted ones) are performed in the sitting position
with the head in a neutral or slightly extended position. Flexion of the
head should be avoided.
[Link] the measurement, the subject (or technician) firmly supports
his/her cheeks and the floor of the mouth using both hands and a nose
clip is worn to eliminate upper airway shunt artifact especially in high
frequencies. (It is also omitted by head generator technique which applies

49
Pulmonary Function Testing Riham
Raafat
oscillating pressure signals around the head and at the mouth minimizing Z but
overcorrecting shunt artifact).

[Link] subject is instructed to breathe quietly (for 30s to measure volumes)

at FRC level (if child, try to help him to practice).

-Quality control:
1. The largest P developed in the system should not exceed 0.5 kPa
2. A peak-to-peak size of the composite signal of 0.1–0.3 kPa seems
optimal.
3. The flowmeter and the pressure transducer should be linear (within
2%) up to at least 1 L·s–1 and up to 0.5 kPa, respectively.
4. Proper calibration and evaluation of the accuracy of FOT set-ups is
particularly important since it has been shown that systematic
differences in Zrs were obtained with different devices with 10%
maximum error.
5. Amplitude spectrum of the composite signal is colored so as to
enhance the power at lower test frequencies. This improves the signal-
to-noise ratio at the lower frequencies that are more contaminated by
components of the spontaneous breathing signal.
6. Averaging pseudorandom signal epochs by time or the use of the so-
called "unbiased estimators" reduces the errors introduced at the low
frequencies.
7. Acceptance criteria: Swallowing, glottis closure, leak around the
mouthpiece, improper seal with the nose clip, irregular breathing or
acute hyperventilation during the measurement  discard it.

50
Pulmonary Function Testing Riham
Raafat

[K] Breath Condensate:

-Definition:
It's a measurement for analysis of non-volatile macro-molecules present
in exhaled breathe including proteins, lipids (leukotriens, peptides,
cytokines), oxidants (hydrogen peroxide), nucleotides (adenosine) as well
as volatile substances (NO & ammonia), isoprostanes, protons and ions by
cooling of H2O vapor expired breath (by wet ice, dry ice or liquid N2).

-Indications:
1. Useful tool for epidemiological investigation (easy collection).
2. Help gain understanding of the time courses of important
pathological processes (oxidative stress, inflammation).
3. Compounds present in different diseases:
 Smokers  H2O2, 8-isoprostane (normally 0-40pg/ml) (5folds > non-
smokers)
 COPD  H2O2, 8-isoprostane, 5-HT, IL-1,6, TNF-a, PG
 BA  H2O2, 8-isoprostone, NO (normally it's 1micromole/L), LT (up to
9fold ↑), Adenosine (normally 2nmol/L), IL-4, acid PH (N=7.4-8.8)
 Chronic bronchitis  LT (normally 4-15pg/ml according to type)
 Bronchiectasis  H2O2 (normally it's 0-0.9 micromole/L), NO
 Cystic fibrosis  H2O2, Nitrite, 8-isoprostone, IL-6,8
 ARDS  H2O2, 8-isoprostane, PGE2 (normally 8pg/ml)
 Pneumonia, cancer, after thoracotomy?  oxidative stress markers
(as aldehydes and lipid peroxides), IL-6 (NSCLC,OSA)
 ILD?  IL-1, SIL-2R, TNF-a, 8-isoprostone

-Factors affecting:
 Velocity of air (inverse proportion)
 Surface tension of extra-cellular lining fluid (directly proportional)

51
Pulmonary Function Testing Riham
Raafat

 Turbulent flow & high No. of edge branching (direct proportion)

*N.B. in TV  aerosol particles 0.1-4/cm³ with mean diameter
<0.3mcm.

-Technique:
a. Tidal breathing by mouth piece or nasally or through mechanical
ventilator expiratory limb or BAL sample.
b. The use of nose clip may well minimize the aerosolisation of particles
from the nasopharynx. On the other hand, volatile gases formed in the
nasopharynx (such as NO) may be entrained to a greater extent in the
exhaled air when nose clips are employed (as the case for NO).
c. Condensate (visible white particles stored at -70°C) of about 1-3ml is
collected in containers (glass, polystyrene or polypropylene (best)) in
5-10mins in adults & in 15-20mins in children  amount depends on
minute ventilation and humidity.
d. To detect PH  must stabilize condensate by gas standardization (de-
aeration) with CO2 free gas (as argon, nitrogen oxygen or another).

-Advantages:
a. Simple.
b. Inclusive rather than intrusive (used in any age and any place).
c. Portable and Longitudinal sampling.
d. Solute clearance.
e. Amplified DNA and RNA from prokaryotic and eukaryotic cells.

-Disadvantages:
a. Lack of standard breath sampling method.
b. Lack evidence for the exact origin of aerosol particles.
c. Concentration artifact due to evaporation (about 35 ml lost).
d. Oxidative stress isn't tested in relation to the biomarkers released.

52
Pulmonary Function Testing Riham
Raafat

e. Little information on biomarkers of ILD.

[L] Cardio-pulmonary exercise test (CPX):
-Definition:
 Involves the assessment of cardio-pulmonary function during
incremental exercise and combines the routine measurements of the
ECG, ABP and power output with the analysis of exhaled gases.
 It is typically ordered when a patient is complaining of shortness of
breath, dyspnea on exertion, or exercise intolerance.
 When a patient complains of chest pain or other symptoms of
cardiovascular disease, the more appropriate test would be a cardiac
stress test performed by a cardiologist.
 If the patient complains of chest tightness and wheezing during or
after exercise, the more appropriate test would be an exercise
challenge  gas exchange measurements are unnecessary.

-Indications:

1. Determination of the exercise capacity.

2. Determination of the cause of any exercise impairment.
3. Detection of covert pulmonary disease (early IPF).
4. Identification of abnormal responses to exercise (as induced BS).
5. Risk stratification & exercise response for training and rehabilitation.
6. Evaluation of results of treatment.
7. Pre-operative evaluation & Selection of pts for cardiac transplantation.
8. Impairment/disability evaluation (CPX + spirometry, DLCO, ABG,
pulse and BP at rest).
9. Documentation of exercise induced hypoxia (low maximum O2
consumption (VO2max)).
[Link] unexplained dyspnea.

53
Pulmonary Function Testing Riham
Raafat

[Link] pt. has moderate impairment on resting tests but clinically appearing
severely impaired.
-Contraindications: the same as ECT (see page 27)

-Technique:
 Patient's preparation: the same as ECT
 Devices used: (see pages 28-29)
 Technique:
o Instruct the patient and let him understands
o Knees are 20° when pedals are down
o Mouthpiece & nasal clip are used with quiet breathing for 2-3mins
o Pulse oximeter (better on ear probe here) and ECG and BP (pre, in)
o Stop test if:
a. Progressive angina (three on a one to four
scale)
b. Ventricular tachycardia
c. A significant drop (>20/10 mmHg) in blood
pressure or failure of the systolic blood pressure to rise over several
minutes of incrementally increasing power output.
d. Excessive rise in blood pressure:
>250/120mmHg
e. >2-4 mm horizontal or down-sloping ST
depression
f. Lightheadedness, confusion, nausea, ataxia, pallor, etc.
g. Onset of second or third degree heart block
h. Exercise-induced left bundle branch block
i. Sustained SVT, increasing ventricular ectopy, or multiple PVCs
j. Termination by the patient (cannot continue), or pt requests to stop

54
Pulmonary Function Testing Riham
Raafat

k. Failure of equipment (the ECG or BP

monitoring system
l. HR increases >85% of predicted (which is 220-pt's age)
m. PO2 decrease more than 5%
n. Decrease in anaerobic threshold (N>6o% of
Vmax): indicates high PCO2

Keep ECG at resting after stoppage for 2-6 mins

o
-Interpretation:
ύ O2 O2 consumption
ύ O2max Maximal O2 consumption
ύE Minute ventilation (expired)
ύ CO2 CO2 production
ύ O2/HR O2 pulse
ύ E / ύ O2 Ventilatory equivalent for oxygen
ύ E / ύ CO2 Ventilatory equivalent for carbon dioxide

AT, VT, GET Anaerobic, Ventilatory or Gas Exchange threshold

RER, RQ, R Respiratory exchange ratio, ύ CO2/ ύ O2

VD/VT% Dead space to tidal volume ratio as a percent

PaO2 Arterial partial pressure of O2
PaCO2 Arterial partial pressure of CO2
PETCO2 End tidal partial pressure of CO2

*Calculations are usually performed by a computerized data acquisition

system

-Quality control:
a. Temperature (20-25 °C)
b. Wide room
c. Frequent calibration daily with 3L syringe
d. Calibrate treadmill or cycle every 3-6 months

55
Pulmonary Function Testing Riham
Raafat

e. Calibrate the grade % of treadmill = vertical height or elevation /

length of treadmill x 100
f. Reusable valves should be pressurized to check for leaks using a
water-column manometer.
g. Check medications for emergencies

-Normal changes with exercise:

 PO2  slightly increase
(The normal Alveolar-arterial O2 gradient [P(A-a)O2] increases with age &
exercise. .At 20 to 39 years of age, the mean P(A-a)O2 is 8 mmHg at rest, and 15
mmHg at maximal exercise.
.At 40 to 69 years of age, the mean P(A-a)O2 is 13 mmHg at rest, and 19 mmHg at
maximal exercise.
.In this older group, at maximum exercise the upper limit of normal (i.e., 95%
confidence interval) is 28 mmHg.
.A general guideline for the upper limit of adults is a P(A-a)O2 <35 mmHg).
 PCO2  slightly decrease due to hyperventilation
 Alveolar ventilation  increases (VD(dead space)/ VT(tidal volume)
decreases)
 DLCO  increases
 PH  compensated or alkalotic (hyperventilation)

[M] Maximum Respiratory Pressure measurement:

-Definitions:
.The measurement of respiratory muscle forces (or strength), maximum
inspiratory pressure (MIP or PImax), and maximum expiratory pressure
(MEP or PEmax), are direct tests that are simple to perform.

56
Pulmonary Function Testing Riham
Raafat

.They assess the aggregate force or pressure that respiratory muscles can

generate against an occlusion at the mouth.

.PImax is an index of diaphragm strength, while PEmax measures the
strength of abdominal and intercostal muscles (Maximum Cough gastric
pressure is measured as an index of abdominal muscle strength. Pgaco
is a useful test to supplement PEmax, particularly in patients unable to
perform the PEmax maneuver reliably).

-Indications:

1. Assess and quantify the degree of respiratory muscular weakness

that may occur with: neuromuscular diseases (e.g., amyotrophic
lateral sclerosis, myasthenia gravis, and polymyositis), obstructive
lung disease causing hyperinflation (e.g., emphysema, chronic
bronchitis, and cystic fibrosis), and conditions requiring chronic
steroid use, conditions with chest deformities, and unexplained
dyspnea.
2. Abnormal diagnostic test results (decreased FVC, PEF, MVV, or
abnormal CXR).
3. The PEmax gives information about the potential for effective cough
and ability for secretion clearance.
4. Diagnosis and management of a patient with actual or suspected
injury to the diaphragm or other respiratory muscles.
5. Evaluate the effectiveness of therapy designed to improve
respiratory muscle strength.

-Contraindications:

Absolute:
a. Unstable angina

57
Pulmonary Function Testing Riham
Raafat

b. Recent MI (within the previous 4 weeks) or myocarditis.

c. Uncontrolled systemic hypertension
d. Recent pneumothorax
e. Lung biopsy within the previous week.

Relative:
1. Resting BP >200/110 mmHg
2. Recent spinal injury
3. Recent eye surgery
4. Non-compliant patient or one who is not capable of performing the
test because of weakness, pain, fever, dyspnea, lack of coordination, or
psychosis.

-Precautions:
 Indications for immediate termination of testing
a. Syncope
b. Angina
c. Lightheadedness not relieved by rest
d. Request from patient to terminate test
 Abnormal responses that may require discontinuation of testing
a. Mental confusion or headache
b. Nausea or vomiting
c. Muscle cramping
 Hazards associated with maximal respiratory force testing
a. Ruptured ear drum
b. Exacerbation of hemorrhoids
c. Syncope
d. Conjunctival hemorrhage

58
Pulmonary Function Testing Riham
Raafat

-Technique:

1. Patient's preparation: instruct and be sure that patient has rested

before testing and assess the patient well.

2. Calibration of the device daily.

3. Patient sits upright with nose clip and mouthpiece in his mouth.

4. Exhales slowly to RV then inhales with maximum force with

maximum pulling in for 1s (can do this 3-8 times with rest in

between for 30-60s).

5. Remove the disposable cardboard or rubber-flanged mouthpiece,

and apply a circular non flanged rubber mouthpiece or other rigidly

constructed tube.
6. Instruct the patient and demonstrate correct placement of the
rubber mouthpiece or tube held firmly against pursed lips (not
inside the mouth like other mouthpieces).
7. Patient inhales to TLC then exhales maximally for 1s (watch for no
leakage)  again can do it for 3-8 trials with rest between efforts.

-Interpretation:
 PImax should be a negative value (cmH2O)  Report the most –ve.
 PEmax should be a positive value (cmH2O)  Report the highest.

 Report the number of efforts, degree of reproducibility, percent of

predicted and lower limit of normal.

 To correct for differences in body size and varied levels of TLC

caused by disease states, pressures can be presented as a percent of
predicted TLC at which they were measured. This is not possible
with handheld devices. (Body plethysmography can be done for this).

59
Pulmonary Function Testing Riham
Raafat

*N.B.:
 Respiratory muscle force may also be assessed by measuring changes
in pleural pressure with an esophageal catheter, by twitch gastric
pressure and by magnetic stimulation over 8-10 thoracic vertebrae.
 Assessment of diaphragm strength can be made by:
a. Abdominal & Esophageal pressures (Sniff esophageal pressure for
global inspiratory muscle strength and maximum Cough gastric
pressure for abdominal muscle strength) via balloon-tipped
catheters placed in the stomach and esophagus, and then
calculating trans-diaphragmatic pressure (Pdi for diaphragmatic
strength).
b. Twitch trans-diaphragmatic pressure (Pdi tw) or by non-invasive
measure like twitch mouth pressure (Pmo tw) (but affected by
obstructing lesions and glottic abnormalities due to inadequate
transmission of alveolar pressure to the mouth).
c. Phrenic nerve stimulation (PNS) is specific for the diaphragm and
is not influenced by CNS (either magnetic which is easier but non-
specific or electrical which is more difficult but more selective).
 Respiratory muscle functions can be detected by electrophysiological
tests like: EMG and stimulation tests (as PNS).

[N] Regional lung function assessment:

-Definition:
The function of each lung or one or more of its subdivisions is detected
alone  before resection surgery mostly.

-Measured by: Carlen's catheter, Rigid bronchoscopy, Long Swan Ganz

catheter or Radioactive isotopes.

*N.B: -ERV: volume of air exhaled after normal expiration in quiet breath (N=1L)

60
Pulmonary Function Testing Riham
Raafat
-IRV: volume of air inhaled at the end of normal TV (N=3L)
-TV: volume used during quiet breathing (N= 0.5L, RR 8-18 b/m)
-Max. VE: volume of air breathed in 1min. during repetitive max. resp. effort.
-Minimum ventilation (MV or V) or respiratory minute volume: volume of air
breathed in 1min (TV x RR) = 6-10 L/min. (inc. with hyperventilation) = Va +
Vd
-Breathing reserve (BR) = MVV – pulmonary ventilation (MV)
-Dyspnea index = (BR/MVV) X 100 (normally >90%)

61