Post on 07-May-2015
2005 PPC Lectures Series: 2005 PPC Lectures Series: Pulmonary Function TestsPulmonary Function Tests
Kimberly Otsuka, M.D.Kimberly Otsuka, M.D.
Pediatric Pulmonary FellowPediatric Pulmonary Fellow
September 19, 2005September 19, 2005
ObjectivesObjectives
Briefly review pulmonary anatomy and Briefly review pulmonary anatomy and physiologyphysiology
Review lung volumes and capacitiesReview lung volumes and capacitiesProvide an overview of pulmonary function Provide an overview of pulmonary function
teststestsDiscuss spirometry and review its clinical Discuss spirometry and review its clinical
applicationsapplications
AnatomyAnatomy
Lungs comprised of Lungs comprised of AirwaysAirways AlveoliAlveoli
http://www.aduk.org.uk/gfx/lungs.jpg
Weibel ER: Morphometry of the Human Lung. Berlin and New York: Springer-Verlag, 1963
The AirwaysThe Airways
Conducting zone: no Conducting zone: no gas exchange occursgas exchange occurs Anatomic dead Anatomic dead
spacespace Transitional zone: Transitional zone:
alveoli appear, but are alveoli appear, but are not great in numbernot great in number
Respiratory zone: Respiratory zone: contain the alveolar contain the alveolar sacssacs
The AlveoliThe Alveoli
Approximately 300 Approximately 300 million alveolimillion alveoli
1/3 mm diameter1/3 mm diameter Total surface area if Total surface area if
they were complete they were complete spheres 85 sq. spheres 85 sq. meters (size of a meters (size of a tennis court)tennis court)
Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed., Copyright © 2000 W. B. Saunders Company
Mechanics of BreathingMechanics of Breathing
InspirationInspirationActive processActive process
ExpirationExpirationQuiet breathing: passiveQuiet breathing: passiveCan become activeCan become active
Lung VolumesLung Volumes
IRV
TV
ERV
4 Volumes4 Volumes 4 Capacities4 Capacities
Sum of 2 or Sum of 2 or more lung more lung volumesvolumes
RV
IC
FRC
VC
TLC
RV
Tidal Volume (TV)Tidal Volume (TV)
IRV
TV
ERV
RV
IC
FRC
VC
TLC
RV
Volume of air Volume of air inspired and inspired and expired during expired during normal quiet normal quiet breathingbreathing
Inspiratory Reserve Volume (IRV)Inspiratory Reserve Volume (IRV)
IRV
TV
ERV
The maximum The maximum amount of air amount of air that can be that can be inhaled after a inhaled after a normal tidal normal tidal volume volume inspirationinspiration
RV
IC
FRC
VC
TLC
RV
Expiratory Reserve Volume (ERV)Expiratory Reserve Volume (ERV)
IRV
TV
ERV
Maximum Maximum amount of air amount of air that can be that can be exhaled from exhaled from the resting the resting expiratory levelexpiratory level
RV
IC
FRC
VC
TLC
RV
Residual Volume (RV)Residual Volume (RV)
IRV
TV
ERV
Volume of air Volume of air remaining in the remaining in the lungs at the end lungs at the end of maximum of maximum expirationexpiration
RV
IC
FRC
VC
TLC
RV
Vital Capacity (VC)Vital Capacity (VC)
IRV
TV
ERV
Volume of air that Volume of air that can be exhaled can be exhaled from the lungs from the lungs after a maximum after a maximum inspirationinspiration
FVC: when VC FVC: when VC exhaled forcefullyexhaled forcefully
SVC: when VC is SVC: when VC is exhaled slowlyexhaled slowly
VC = IRV + TV + VC = IRV + TV + ERVERV
RV
IC
FRC
VC
TLC
RV
Inspiratory Capacity (IC)Inspiratory Capacity (IC)
IRV
TV
ERV
Maximum Maximum amount of air amount of air that can be that can be inhaled from the inhaled from the end of a tidal end of a tidal volumevolume
IC = IRV + TVIC = IRV + TV
RV
IC
FRC
VC
TLC
RV
Functional Residual Capacity Functional Residual Capacity (FRC)(FRC)
IRV
TV
ERV
Volume of air Volume of air remaining in the remaining in the lungs at the end of lungs at the end of a TV expiration a TV expiration
The elastic force of The elastic force of the chest wall is the chest wall is exactly balanced by exactly balanced by the elastic force of the elastic force of the lungsthe lungs
FRC = ERV + RVFRC = ERV + RV
RV
IC
FRC
VC
TLC
RV
Total Lung Capacity (TLC)Total Lung Capacity (TLC)
IRV
TV
ERV
Volume of air in the Volume of air in the lungs after a lungs after a maximum maximum inspirationinspiration
TLC = IRV + TV + TLC = IRV + TV + ERV + RVERV + RV
RV
IC
FRC
VC
TLC
RV
Pulmonary Function TestsPulmonary Function Tests
Evaluates 1 or more major aspects of the Evaluates 1 or more major aspects of the respiratory systemrespiratory systemLung volumesLung volumesAirway functionAirway functionGas exchangeGas exchange
IndicationsIndications
Detect disease Detect disease Evaluate extent and monitor course of Evaluate extent and monitor course of
diseasediseaseEvaluate treatmentEvaluate treatmentMeasure effects of exposuresMeasure effects of exposuresAssess risk for surgical proceduresAssess risk for surgical procedures
Pulmonary Function TestsPulmonary Function Tests
Airway functionAirway function Simple spirometrySimple spirometry Forced vital capacity Forced vital capacity
maneuvermaneuver Maximal voluntary Maximal voluntary
ventilationventilation Maximal Maximal
inspiratory/expiratory inspiratory/expiratory pressurespressures
Airway resistanceAirway resistance
Lung volumes and Lung volumes and ventilationventilation Functional residual Functional residual
capacitycapacity Total lung capacity, Total lung capacity,
residual volumeresidual volume Minute ventilation, Minute ventilation,
alveolar ventilation, alveolar ventilation, dead spacedead space
Distribution of Distribution of ventilationventilation
Pulmonary Function Tests Pulmonary Function Tests
Diffusing capacity Diffusing capacity teststests
Blood gases and gas Blood gases and gas exchange testsexchange tests Blood gas analysisBlood gas analysis Pulse oximetryPulse oximetry CapnographyCapnography
Cardiopulmonary Cardiopulmonary exercise testsexercise tests
Metabolic Metabolic measurements measurements Resting energy Resting energy
expenditureexpenditure Substrate utilizationSubstrate utilization
Chemical analysis of Chemical analysis of exhaled breathexhaled breath
SpirometrySpirometry
Measurement of the pattern of air Measurement of the pattern of air movement into and out of the lungs during movement into and out of the lungs during controlled ventilatory maneuvers.controlled ventilatory maneuvers.
Often done as a maximal expiratory Often done as a maximal expiratory maneuver maneuver
ImportanceImportance
Patients and physicians have inaccurate Patients and physicians have inaccurate perceptions of severity of airflow perceptions of severity of airflow obstruction and/or severity of lung disease obstruction and/or severity of lung disease by physical examby physical exam
Provides objective evidence in identifying Provides objective evidence in identifying patterns of diseasepatterns of disease
Lung Factors Affecting Lung Factors Affecting SpirometrySpirometry
Mechanical properties Mechanical properties Resistive elementsResistive elements
Mechanical PropertiesMechanical Properties
ComplianceComplianceDescribes the stiffness of the lungsDescribes the stiffness of the lungsChange in volume over the change in Change in volume over the change in
pressurepressureElastic recoilElastic recoil
The tendency of the lung to return to it’s The tendency of the lung to return to it’s resting stateresting state
A lung that is fully stretched has more elastic A lung that is fully stretched has more elastic recoil and thus larger maximal flowsrecoil and thus larger maximal flows
Resistive PropertiesResistive Properties
Determined by airway caliberDetermined by airway caliberAffected byAffected by
Lung volumeLung volumeBronchial smooth musclesBronchial smooth musclesAirway collapsibilityAirway collapsibility
Factors That Affect Lung VolumesFactors That Affect Lung Volumes
AgeAgeSexSexHeightHeightWeightWeightRaceRaceDiseaseDisease
TechniqueTechnique
Have patient seated comfortablyHave patient seated comfortablyClosed-circuit techniqueClosed-circuit technique
Place nose clip onPlace nose clip onHave patient breathe on mouthpieceHave patient breathe on mouthpieceHave patient take a deep breath as fast as Have patient take a deep breath as fast as
possiblepossibleBlow out as hard as they can until you tell Blow out as hard as they can until you tell
them to stopthem to stop
TerminologyTerminology
Forced vital capacity Forced vital capacity (FVC):(FVC): Total volume of air that can Total volume of air that can
be exhaled forcefully from be exhaled forcefully from TLCTLC
The majority of FVC can be The majority of FVC can be exhaled in <3 seconds in exhaled in <3 seconds in normal people, but often is normal people, but often is much more prolonged in much more prolonged in obstructive diseasesobstructive diseases
Measured in liters (L)Measured in liters (L)
FVCFVC
Interpretation of % predicted:Interpretation of % predicted: 80-120%80-120% NormalNormal 70-79%70-79% Mild reductionMild reduction 50%-69%50%-69% Moderate reductionModerate reduction <50%<50% Severe reductionSevere reduction
FVC
TerminologyTerminology
Forced expiratory volume Forced expiratory volume in 1 second: (FEVin 1 second: (FEV11)) Volume of air forcefully Volume of air forcefully
expired from full inflation expired from full inflation (TLC) in the first second(TLC) in the first second
Measured in liters (L)Measured in liters (L) Normal people can exhale Normal people can exhale
more than 75-80% of their more than 75-80% of their FVC in the first second; FVC in the first second; thus the FEV1/FVC can be thus the FEV1/FVC can be utilized to characterize utilized to characterize lung diseaselung disease
FEVFEV11
Interpretation of % predicted:Interpretation of % predicted: >75%>75% NormalNormal 60%-75%60%-75% Mild obstructionMild obstruction 50-59%50-59% Moderate obstructionModerate obstruction <49%<49% Severe obstructionSevere obstruction
FEV1 FVC
TerminologyTerminology
Forced expiratory flow 25-Forced expiratory flow 25-75% (FEF75% (FEF25-7525-75)) Mean forced expiratory flow Mean forced expiratory flow
during middle half of FVC during middle half of FVC Measured in L/secMeasured in L/sec May reflect effort May reflect effort
independent expiration and independent expiration and the status of the small the status of the small airwaysairways
Highly variableHighly variable Depends heavily on FVCDepends heavily on FVC
FEFFEF25-7525-75
Interpretation of % predicted:Interpretation of % predicted:>60%>60% NormalNormal40-60%40-60% Mild obstructionMild obstruction20-40%20-40% Moderate obstructionModerate obstruction<10%<10% Severe obstructionSevere obstruction
Acceptability CriteriaAcceptability Criteria
Good start of testGood start of testNo coughingNo coughingNo variable flowNo variable flowNo early terminationNo early terminationReproducibilityReproducibility
Flow-Volume LoopFlow-Volume Loop
Illustrates maximum Illustrates maximum expiratory and expiratory and inspiratory flow-inspiratory flow-volume curvesvolume curves
Useful to help Useful to help characterize disease characterize disease states (e.g. states (e.g. obstructive vs. obstructive vs. restrictive)restrictive)
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
Categories of DiseaseCategories of Disease
ObstructiveObstructiveRestrictiveRestrictiveMixedMixed
Obstructive DisordersObstructive Disorders
Characterized by a Characterized by a limitation of expiratory limitation of expiratory airflowairflow Examples: asthma, Examples: asthma,
COPDCOPD
Decreased: FEVDecreased: FEV11, ,
FEFFEF25-7525-75, FEV, FEV11/FVC /FVC
ratio (<0.8)ratio (<0.8) Increased or Normal: Increased or Normal:
TLCTLC
Spirometry in Obstructive Spirometry in Obstructive DiseaseDisease
Slow rise in upstrokeSlow rise in upstroke May not reach May not reach
plateauplateau
Restrictive Lung DiseaseRestrictive Lung Disease
Characterized by diminished lung Characterized by diminished lung volume due to:volume due to: change in alteration in lung change in alteration in lung
parenchyma (interstitial lung parenchyma (interstitial lung disease) disease)
disease of pleura, chest wall disease of pleura, chest wall (e.g. scoliosis), or (e.g. scoliosis), or neuromuscular apparatus (e.g. neuromuscular apparatus (e.g. muscular dystrophy)muscular dystrophy)
Decreased TLC, FVCDecreased TLC, FVC Normal or increased: FEVNormal or increased: FEV11/FVC /FVC
ratioratio
Restrictive DiseaseRestrictive Disease
Rapid upstroke as Rapid upstroke as in normal in normal spirometryspirometry
Plateau volume is Plateau volume is lowlow
Large Airway ObstructionLarge Airway Obstruction
Characterized by a Characterized by a truncated truncated inspiratory or inspiratory or expiratory loopexpiratory loop
Lung VolumesLung Volumes
Measured through various methodsMeasured through various methodsDilutional: helium, 100% oxygenDilutional: helium, 100% oxygenBody plethysmographyBody plethysmography
Changes in Lung Volumes in Changes in Lung Volumes in Various Disease StatesVarious Disease States
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
Clinical ApplicationsClinical Applications
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