Spirometry and Pulmonary Function Test

dr. Ahmad Rasyid, SpPD, K-P, FINASIM

What is Spirometry?. Spiro - from the Greek for ‘breathing’, metry –measurement →
SPIROMETRY – the measurement of breathing → Spirometry is a methode of assessing lung
function by measuring the volume of air the patient can expel from the lungs after a maximal
expiration. Why do you need to use a spirometer ? → :
- Accurate diagnosis of obstructive and restrictive lung disease
- Assess severity of airflow obstruction and monitoring of disease progression in COPD
- Screening smokers and detects airflow obstruction in smokers who may have few or no
symptoms
- Assess one aspect of response to therapy
- Screen workforces in occupational environtments and, diagnosis and monitoring of
occupational lung disease
- Assess fitness to dive
- Perform pre-employment screening in certain professions
- Perform pre-operative assessment

Possible side effect : feeling light-headed, headache, getting red in the face, fainting
→reduced venous return or vasovagal attack (reflex), transient urinary incontinence.
WHO SHOULD NOT BE ASKED TO PERFORM SPIROMETRY? Relative
contraindications to performing forced expiratory manoeuvres, but spirometry should be
avoided after recent heart attack or stroke.
PRACTICAL SESSION. Performing Spirometry : →To obtaining Predicted Values :
→ Independent of the type of spirometer, choose values that best represent the tested
population and check for appropriateness if built into the spirometer
→ Withholding Medications : Before performing spirometry, withhold bronchodilators :
- Short acting β2-agonists for 4-6 hours
- Long acting inhaled β2-agonists for 12 hours
- Ipratropium for 6 hours
- Tiotropium for 24 hours
- Oral bronchodilators (sustained release) for 24 hours.
- Comfortable, loose clothing
- Avoid eating a substantial meal within 2 hours of testing
- Avoid vigorous exercise within 30 minutes of testing
Performing Spirometry : → preparation :
- Explain the purpose of the test and demonstrate the procedure
- Record the patient’s age, height and gender and enter on the spirometer
- Note when bronchodilator was last used
- Have the patient sitting comfortably
- Loosen any tight cloth
- Empty the bladder beforehand if needed

Performing Spirometry
- Breath in until the lungs are full
- Hold the breath and seal the lips tightly around a clean mouthpiece
- Blast the air out as forcibly and fast as possible. Provide lots of encouragement!
- Continue blowing until the lungs feel empty
- Watch the patient during the blow to assure the lips are sealed around the mouthpiece
- Check to determine if an adequate trace has been achieved
Repeat the procedure at least twice more until ideally 3 readings within 100 ml, or 5% of each
other are obtained. Most common cause of inconsistent readings is poor patient technique
 Sub-optimal inspiration
 Sub-maximal expiratory effort
 Delay in forced expiration
 Shortened expiratory time
 Air leak around the mouthpiece
Subjects must be observed and encouraged throughout the procedure.
Common problem :
- Inadequat or incomplete blow
- Lack of blast effort during exhalation
- Slow start to maximal effort
- Lips not sealed around mouthpiece
- Coughing during the blow
- Extra breath during the blow
- Glottic closure or obstruction of mouthpiece by tounge or teeth
- Poor posture → leaning forward
Lung Volume Terminology :

Lung Volume Terminology

Inspiratory reserve Inspiratory

volume capacity

Total Tidal volume

lung
capacity
Expiratory reserve Vital
volume capacity

Residual volume

Standard Spirometric Indicies:

FEV1 - Forced expiratory volume in one second: The volume of air expired in the first second of
the blow
FVC - Forced vital capacity:The total volume of air that can be forcibly exhaled in one breath
FEV1/FVC ratio: The fraction of air exhaled in the first second relative to the total volume
exhaled
Additional Spirometric Indicies
VC - Vital capacity: A volume of a full breath exhaled in the patient’s own time and not forced.
Often slightly greater than the FVC, particularly in COPD
FEV6 – Forced expired volume in six seconds: Often approximates the FVC. Easier to perform
in older and COPD patients but role in COPD diagnosis remains under investigation
MEFR – Mid-expiratory flow rates: Derived from the mid portion of the flow volume curve but
is not useful for COPD diagnosis

Spirogram patterns :
- Normal
- Obstructive
- Restrictive
- Mixed Obstructive and Restrictive
Spirometry : Predicted Normal Values depends on : Age, Height, Sex and Ethnic Origin.
Criteria for Normal : → Post-bronchodilator Spirometry :
- FEV1: % predicted > 80%
- FVC: % predicted > 80%
- FEV1/FVC: > 0.7
Normal Trace Showing FEV1 and FVC

Normal Trace Showing FEV1 and FVC

5 FVC
Volume, liters

4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1

1 2 3 4 5 6

Time, seconds

Spirometry: Obstructive Disease

Diseases associated with airflow obstruction :
- COPD
- Asthma
- Bronchiectasis
- Cystic Fibrosis
- Post-tuberculosis
- Lung cancer (greater risk in COPD)
- Obliterative Bronchiolitis
Spirometric Diagnosis of COPD : COPD is confirmed by post–bronchodilator FEV1/FVC < 0.7.
Post-bronchodilator FEV1/FVC measured 15 minutes after 400µg salbutamol or equivalent
CRJ1

Spirometry: Obstructive Disease

5
4
Volume, liters

Normal
3
FEV1 = 1.8L
2 Obstructive
FVC = 3.2L
1 FEV1/FVC = 0.56

1 2 3 4 5 6
Time, seconds
Bronchodilator Reversibility Testing : → Provides the best achievable FEV1 (and FVC). Helps to
differentiate COPD from asthma. Must be interpreted with clinical history - neither asthma nor
COPD are diagnosed on spirometry alone. Bronchodilator Reversibility Testing can be done on
first visit if no diagnosis has been made. Best done as a planned procedure : pre-and post-
bronchodilator tests require a minimum of 20 minutes. Post-bronchodilator only saves time but
does not help confirm if asthma is present. Short-acting bronchodilators need to be withheld for
at least 4 hours prior to test

Bronchodilator Reversibility Testing

Bronchodilator Reversibility Testing

Bronchodilator* Dose FEV1 before

and after
Salbutamol 200 – 400 µg via large 15 minutes
volume spacer
Terbutaline 500 µg via Turbohaler® 15 minutes

Ipratropium 160 µg** via spacer 45 minutes

* Some guidelines suggest nebulised bronchodilators can be given but the doses
are not standardised. “There is no consensus on the drug, dose or mode of
administering a bronchodilator in the laboratory.” Ref: ATS/ERS Task Force :
Interpretive strategies for Lung Function Tests ERJ 2005;26:948
** Usually 8 puffs of 20 µg

Preparation : Test should be performed when patients are clinically stable and free from
respiratory infection. Patient should not have taken :
- Inhaled short-acting bronchodilators in the previous 6 hours
- Long acting bronchodilators in the previous 12 hours
- Sustained-release theophylline in the previous 24 hours

FEV1 should be measured (minimum twice, within 5%) before bronchodilator is given.
The bronchodilator should be given by metered dose inhaler through a spacer device or
by nebulizer to be certain it has been inhaled. The bronchodilator dose should be selected
to be high on the dose/response curve. Possbile dose protocols : - 400 µg B2 agonist, or
80-160 µg anticholinergic, or the two combined. FEV1 should be measured again 10-15
minutes after a short- acting B2-agonist, 30-45 minute after the combination.
Result : - An incease in FEV1 that is both greater than 200 ml and 12% above the
prebronchodilator FEV1 (baseline value) is considered significant. It is usually helpful to
report the absolute change ( in ml) as well as the % change from baseline to set the
improvement in a clinical context.
Spirometry: Restrictive Disease
FEV1: % predicted < 80%
FVC: % predicted < 80%
FEV1/FVC: > 0.7

Spirometry: Restrictive Disease

5 Normal
Volume, liters

4
3
Restrictive FEV1 = 1.9L
2
FVC = 2.0L
1
FEV1/FVC = 0.95

1 2 3 4 5 6
Time, seconds

Diseases Associated with a Restrictive Defect :

Pulmonary :
- Fibrosing lung diseases (CFA, EAA, rheumatoid)
- Pneumoconiasis (coal workers, asbestosis, silicosis, siderosis)
- Bissynosis
- Pulmonary edema
- Parenchymal lung tumors
- Lobectomy or pneumonectomy

Extrapulmonary :
- Thoracic cage deformity
- Obesity
- Pregnancy
- Neuromuscular disorders
- Fibrothorax
- Cardeiac failure
- Neuromuscular problem

Mixed (Combined Obstructive/Restrictive)

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

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

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

Diseases associated with a Combined Defects : Severe COPD, Advanced bronchiectasis, cystic
fibrosis.

Parameters affected
Obstructive
Obstructive Restrictive
Restrictive Combined
Combined

FEV 11 < 80% < 80% < 80%

FVC > 80% < 80% < 80%

RATIO < 70% > 70% < 70%

education for health

Spirometry: Abnormal Patterns

Obstructive Restrictive Mixed

Volume
Volume

Volume

Time Time Time

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

volume expired; at reduced maximum volume;
prolonged time to maximum volume measure static lung
full expiration volumes and full PFT’s
to confirm
Unacceptable Trace : → - Poor Effort, Stop Early, Slow Start and coughing

Unacceptable Trace - Poor Effort

Volume, liters
Normal
Variable expiratory effort
Inadequate sustaining of effort

May be accompanied by a slow start

Time, seconds

Unacceptable Trace – Stop Early

Normal
Volume, liters

Time, seconds

Unacceptable Trace – Slow Start

Normal
Volume, liters

Time, seconds

Unacceptable Trace - Coughing

Normal
Volume, liters

Time, seconds
PARAMETERS AFFECTED

Parameters affected
Obstructive Restrictive Combined

FEV 11 < 80% < 80% < 80%

FVC > 80% < 80% < 80%

RATIO < 70% > 70% < 70%

education for health