Introduction to Pulmonary Function Testing

Medicine Noon Conference

July, 2008

Frank Jacono, M.D.

Pulmonary, Critical Care
& Sleep Medicine
 Case #1

• 65-year old male with 3-week history of an increasingly

productive cough (change in sputum color from white to
yellow), increased dyspnea (shortness of breath with mild
exertion – walking to the bathroom) and wheezing.
• Pt denies hemoptysis, nasal discharge, sore throat or chest
pain.
• Chronic cough which is worse in the morning. He has been on
home oxygen for one year. Quit smoking 7 years ago, prior 2.5
packs/day for 40 years).

• Based on history, what is your diagnosis?

• What are risk factors for this condition?
 Case #1

• Meds: Home O2 at 2 L/min; Tiotropium 1 inhalation daily,

fluticasone MDI (110mcg) 2 puffs BID, albuterol MDI prn

• Exam: 37.7, 110/65, 122, 32. Audible wheezing and

accessory muscle use. Chest expansion is symmetrical,
hyperresonant to percussion, with diffuse wheezes and
prolonged expiratory phase.

• ABG (2L) 7.32/58/55

• What are the 5 causes of hypoxia?

• What would you expect to see on CXR?
• What would you expect to see on spirometry?
 CXR

• Lungs are large and hyper inflated.

• Signs of hyperinflation are
– Low set diaphragm
– Flat diaphragm best determined
by lateral chest
– Hyper-lucent lung fields
– Increased AP diameter
– Increased retro-sternal air
– Vertical heart
Spirometry

Meas Ref %Pred

FVC 3.66 4.39 83
FEV1 1.03 2.87 36
FEV1/FVC 28 65
FEF25-75 0.33 2.48 13
PEF 4.29 8.33 52
 Overview

• Pulmonary function tests are vastly under utilized

– uncomfortable with interpretation

• Population surveys document some abnormality in pulmonary

function in 5-20% of subjects studied

• In a disease such as COPD, by the time dyspnea develops,

airway obstruction is moderately advanced
 Common Uses of PFTs

1. To evaluate respiratory symptoms

2. To determine severity of impairment in patients with known

respiratory disease

3. To follow the course of disease in a patient, including the

response to therapy

4. To assess preoperative risk for predicting postoperative

respiratory complications

5. To screen for subclinical disease

 Potential Shortcomings of PFT’s

• Variability in the normal predicted values of various tests

• Requires a pulmonary function technician with considerable

technical expertise.
– training
– experience

• Height and weight measured at the time of testing

 Standard Tests of Lung Function

• Spirometry: Dynamic Lung Volumes

• Static Lung Volumes

• Diffusing Capacity (DLCO)

• Arterial Blood Gas (ABG)

 Specialized Tests of Lung Function

• Bronchial challenge testing

• Ventilatory muscle studies

• Ventilatory drive studies

• Physiologic shunt studies

• Cardiopulmonary exercise testing

• Six minute walk

Spirometry
Lung Volumes and Capacities
 Volume-Time Spirogram
Volume (L )

1)Tidal volume respirations

2) At end expiration, patient

performs maximal inspiration
to TLC, followed by

3) Exhalation as hard and as

fast as possible until “all the air
FVC is out”

•The volume of air exhaled is

the FVC
RV
•The remaining volume of air
in the lungs is RV
Flow-Volume Loop

FEV1
•Flow-volume loop is obtained when
the patient inhales quickly and deeply
to TLC after completion of the FVC
maneuver
 Acceptability Of Test

•A clear start to the test with an apparently maximum effort

•A smooth, continuous exhalation maintained for at least

6 seconds, without coughing or Valsalva’s maneuver

•An obvious end to the test (no change in volume for at least 2
seconds)

•Subject should perform a minimum of three and a maximum

of eight FVC maneuvers until at least two acceptable curves
are obtained

•The reproducibility of the two largest curves should be within

5% or 0.1 L, whichever is greater

•The recorded FVC should be the maximum value from the

acceptable curves
 Measurements Derived from Spirometry

• Vital Capacity (VC)- the maximal volume of air exhaled with

maximally forced effort from a position of maximal inspiration
(vital capacity / TLC) performed with a maximally forced
expiratory effort.
– Forced vital capacity (FVC)
– Slow vital capacity (SVC)

• FEV1- the volume of air exhaled in the first second during the
performance of the FVC
 Calculated Indices

Volume (L ) FEV1
•Represents flow in both large and small airways
•Measured directly on the volume axis after 1 second
from the start of expiration

FEV1 VC
•Calculated ratio used to diagnose
obstructive airway disease
FVC

FEF25-75
•Forced expiratory flow measured between 25%
and 75% of the FVC
•Reflects flow in the small airways of the lung
(<2mm in diameter)
Flow-Volume Loop

FEV1 •Represents flow in both large and

small airways
•Measured directly on the volume
axis after 1 second from the start
of expiration

FEV1

FEV1 VC •Calculated ratio used to

diagnose obstructive
airway disease

FEF50 •Forced expiratory flow at 50% of the

FVC
•Analogous to the FEF25-75 that was
measured on the volume-time plot

FIF50 •Forced inspiratory flow at 50% of

the inspiratory vital capacity
 FEV1/VC Ratio

• Expressed as a percentage (%)

• normal ratio is 70%-85%

• Disproportionate reduction of maximal airflow (i.e. FEV1) in relation

to maximal volume (i.e. VC) implies an obstructive impairment
– (FEV1/VC < LLN)

• Concomitant reduction of FEV1 and VC with normal or nearly

normal FEV1/VC ratio:
– Failure of patient to inhale or exhale completely
– May occur in severe obstruction when subject cannot exhale
long enough to empty lungs to RV
• Look for normal TLC and reduced FEF75
• Look for concave appearance of flow-volume curve
– Otherwise is suggestive of a restrictive impairment
 Patterns of Lung Dysfunction Defined by Spirometry

• Obstructive - characterized by reductions in flow

– reduced FEV1/VC ratio below the 5th percentile of the predicted value (ATS)
• Often use FEV1/VC < 70%

– severity of obstruction is defined by the FEV1 percent predicted

• May be physiologic variant % Pred FEV1 > 100
• Mild % Pred FEV1 < 100 and > 70
• Moderate % Pred FEV1 < 70 and > 60
• Moderately-severe % Pred FEV1 < 60 and > 50
• Severe % Pred FEV1 < 50 and > 35
• Very severe % Pred FEV1 < 35
– FEF25-75 may show “early changes” but does not define obstruction

• Restrictive - characterized by decreased lung volumes

– reduced FVC, and FEV1/VC ratio normal
– definitive findings requires a reduced total lung capacity (TLC) < 80% predicted
Classification by Severity – GOLD Criteria

[Link]
 Response to Bronchodilators

• >12% increase in FEV1 or FVC

AND

• >200cc increase in FEV1 or FVC

Normal Flow Volume Loop

• Rapid peak expiratory flow rate

• Gradual decline in flow back to zero
• Inspiratory portion of the loop is a
deep curve plotted on the negative
portion of the flow axis.
• Inspiratory data is often overlooked
Obstructive Airway Diseases
Severe Obstructive Lung Disease

• Curve descends more quickly than normal

and takes on a concave shape, reflected by
a marked decrease in the FEF25-75.
• With more severe disease, the peak
becomes sharper and the expiratory flow
rate drops precipitously.
Variable Effort
Early Glottic Closure
Cough
[Link]
 Case #2

• 72-year old male heavy ex-smoker with chronic cough and

wheezing. Data meet ATS criteria but actively wheezing
during exam.
• Spirometry:

Meas Ref %Pred

FVC 1.3 2.13 61
FEV1 0.95 1.51 63
FEV1/FVC 73.1 70.8
FEF25-75 0.41 1.21 34
Restrictive Lung Disease

• Both the FEV1 and FVC are reduced

proportionately
• Normal or even elevated FEV1/VC ratio
• Overall size of the curve will appear smaller
when compared to normals on the same scale
• Restrictive lung disease cannot be diagnosed
by spirometry alone.
• Contrast to this loop:
 Measurement of Lung Volumes

1. Closed-Circuit Helium
Dilution

2. Open-Circuit Nitrogen
Washout

3. Body Plethysmography

Advantages: Rapid measurements, More accurate than gas techniques

in obstructive airway disease (bulla)

Disadvantages: Expensive, More complex than gas techniques,

Unable to use in claustrophobic or severely obese patients
Lung Volumes and Capacities
Lung Volumes and Capacities
 Diagnosis of a Restrictive Process

• May be suspected based on a decreased VC without a reduction

of the FEV1/FVC ratio
• However, this is most reliably interpreted on the basis of the TLC

• Severity of the abnormality may be graded as follows:

• Mild % Pred TLC < LLN but > 70

• Moderate % Pred TLC < 70 but > 60
• Moderately-severe % Pred TLC < 60

• Different mechanisms may contribute:

Interstitial fibrosis – increased elastic recoil

Diaphragmatic paralysis – respiratory muscle weakness
Kyphoscoliosis – altered chest wall configuration
Pleural effusions – compression of underlying lung parenchyma

• DLCO may help differentiate

DLCO
 Guide to Interpreting Pulmonary Function Tests

FEV1/VC < LLN (70%) ?

(Actual ratio!) **

Yes: No:
Obstructive Normal or Restrictive
Ventilatory Defect Ventilatory Defect

FVC > 80% ? TLC < LLN (80%) ? **

No:
Yes: Yes: No:
May have mixed restrictive
Pure Obstructive Defect Restrictive Disease Normal Spirometry
and obstructive disease

Grade severity of obstruction based on Grade severity of FEF25-75 < 60% or

Examine Lung Volumes
the FEV1 percent predicted restriction based on TLC persistent symptoms ?

Yes: No:
DLCO/VA < 70 %
Consider Methacholine challenge test Normal

Yes: No:
Intrathoracic Restriction Extrathoracic Restriction

Test Respiratory Muscle Strength

** ATS recommends using the “lower limit of

normal” as the cutoff (i.e. below the 5th percentile
of the predicted value). Using 70% or 80%,
respectively, as a cutoff is reasonable in most
cases. However, this approach should be utilized
with caution. Clinical correlation is helpful.
Guide to Interpreting Pulmonary Function Tests

Eur Respir J 2005; 26: 948-968

 Case #3

• 36-year old female recently extubated following prolonged

ventilatory support during treatment for severe pneumonia and
ARDS. Exam is significant for stridor. Bedside flow-volume
loop is obtained.
• What is your diagnosis?
 Flow-Volume Loop as a Diagnostic Indicator

• Useful as a diagnostic tool in patients with suspected

upper airway obstruction

• Upper airway obstruction can occur at the level of:

– pharynx
– larynx
– trachea
– mainstem bronchi
Normal Spirometry
 Upper Airway Obstruction

1. Fixed Obstruction

2. Variable Obstruction

• Intrathoracic

• Extrathoracic
 Upper Airway Obstruction

1. Fixed Obstruction - Geometry and cross-sectional area of the

lesion do not change with the respiratory cycle, so both inspiration and
expiration are affected equally
• Example: tracheal stenosis, bilateral vocal cord paralysis, goiter

2. Variable Obstruction – configuration of the obstructive lesion

changes with the phases of respiration
•Intrathoracic – lesion located below the sternal notch, so the
expiratory limb of the flow-volume loop is predominately affected
•Example: tracheomalacia, neoplasm, Wegner’s granulomatosis

•Extrathoracic – lesion located above the sternal notch, so the

inspiratory limb of the flow-volume loop is predominately affected
•Example: vocal cord paralysis
Fixed Obstruction of the Upper Airway

The fixed obstruction limits flow equally

during inspiration and expiration, and FEF
= FIF. Top and bottom of the loop are
flattened so that the configuration
approaches that of a rectangle.
Examples include tracheal stenosis,
bilateral vocal cord paralysis, and goiter.
Variable Intrathoracic Obstruction

During a forced inspiration, negative pleural

pressure holds the "floppy" trachea open.
With forced expiration, pleural pressures
reach and then exceed intratracheal
pressures, and the loss of structural support
results in narrowing of the trachea and a
plateau of diminished flow. A brief period
of maintained flow is seen before airway
compression occurs. An example is
tracheomalacia.
Variable Extrathoracic Obstruction

During forced expiration, tracheal pressure exceeds

atmospheric pressure. The obstruction is passively
blown aside, and expiratory flow is unimpaired.
Conversely, during forced inspiration, intratracheal
pressure becomes less than atmospheric pressure.
The obstruction is drawn inward, resulting in a
plateau of decreased inspiratory flow. Thus,
FIF<FEF. An example is vocal cord paralysis.
 Sample PFT #1

• A 75 year old female has a history of dyspnea and palpitations.

Meas Ref %Pred

FVC 2.62 2.82 93

FEV1 1.45 1.98 73

FEV1/FVC 55 70

FEF25-75 0.43 2.20 20

PEF 4.50 5.48 82

 Sample PFT #2

• A 66 year old female complains of cough after dust exposure.

Meas Ref %Pred

FVC 2.20 2.58 85
FEV1 1.79 1.85 97
FEV1/FVC 81 72
FEF25-75 1.82 2.23 82
PEF 5.67 5.20 109
 Sample PFT #3

• A 53 year old female has a history of chest tightness.

Meas Ref %Pred

FVC 5.08 4.94 103
FEV1 2.66 3.58 74
FEV1/FVC 52 72
FEF25-75 1.40 3.47 40
PEF 6.49 9.10 71
 Sample PFT #4

• A 55 year old male is evaluated preoperatively for cataract surgery.

Meas Ref %Pred

FVC 1.85 4.60 40
FEV1 0.92 3.33 28
FEV1/FVC 50 72
FEF25-75 0.28 3.28 9
PEF 3.82 8.55 45
 Sample PFT #5

• A 66 year old male retired firefighter presents for wheezing with exertion.

Meas Ref %Pred

FVC 2.78 2.75 101
FEV1 1.90 1.90 100
FEV1/FVC 69 69
FEF25-75 0.95 2.35 40
PEF 4.82 5.45 88
 Sample PFT #6

• A 75 year old female is pre-operatively evaluated for mastectomy.

Meas Ref %Pred

FVC 3.66 4.39 83
FEV1 1.03 2.87 36
FEV1/FVC 28 65
FEF25-75 0.33 2.48 13
PEF 4.29 8.33 52
 Sample PFT #7

• A 65 year old male complains of dyspnea after mitral valve replacement.

Meas Ref %Pred

FVC 3.00 4.79 63
FEV1 2.54 3.28 77
FEV1/FVC 85 69
FEF25-75 3.25 2.97 109
PEF 9.12 8.92 102
 Sample PFT #8

• A 38 year old female complains of wheezing on exertion.

Meas Ref %Pred

FVC 3.66 3.54 103
FEV1 2.30 2.77 83
FEV1/FVC 63 78
FEF25-75 2.15 4.20 51
PEF 2.39 6.25 38
 Sample PFT #9

• A 26 year old woman with a hoarse voice complains of shortness of breath.

Meas Ref %Pred

FVC 4.11 4.34 95
FEV1 3.28 3.47 94
FEV1/FVC 80 80
FEF25-75 3.21 3.85 83
PEF 5.63 7.06 80
 Sample PFT #10

• A 69 year old male has a chronic cough.

Meas Ref %Pred

FVC 4.09 4.25 96
FEV1 1.95 2.88 68
FEV1/FVC 48 68
FEF25-75 0.48 2.65 18
PEF 6.27 8.06 78
G lobal Initiative for Chronic
bstructive
O ung
L isease
D