Pulmonary function test

Part I

Dr.Mona Allangawi Consultant Pulmonary/Allergy

Hamad General Hospital - HMC

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Pulmonary function test :

Group of procedures that measure the function of the lungs
1. 2. 3. 4.

Spirometry Lung volumes Gas transfer Bronchial chalenge

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Indications

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A.Diagnostic

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Symptoms: dyspnea, wheezing, orthopnea, cough, phlegm production, chest pain Signs: decreased breath sounds, overinflation, expiratory slowing, cyanosis, chest deformitory, unexplained crackles Abnormal laboratory tests: hypoxemia, hypercapnia, polycythemia, abnormal chest radiographs  To measure the effect of disease on pulmonary function
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To screen individuals at risk of having pulmonary diseases 1. Smokers 2. Individuals in occupations with exposures to injurious substances To assess preoperative risk To assess prognosis (lung transplant, etc.) To assess health status before enrollment in strenuous physical activity programs

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B. Monitoring

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To assess therapeutic interventions

 




Bronchodilator therapy Steroid treatment for asthma, interstitial lung disease, etc. Other (antibiotics in cystic fibrosis, etc.)
To monitor for adverse reactions to drugs with known pulmonary toxicity

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C. Disability/Impairment Evaluations

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To assess patients as part of a rehabilitation program  Medical  Industrial  Vocational To assess risks as part of an insurance evaluation

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Contraindications

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Hemoptysis of unknown origin Pneumothorax Unstable angina pectoris Recent myocardial infarction Thoracic aneurysms Abdominal aneurysms Cerebral aneurysms Recent eye surgery (increased intraocular pressure during forced expiration) Recent abdominal or thoracic surgical procedures History of syncope associated with forced exhalation

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Pulmonary function test:

1. 2. 3. 4.

Spirometry Lung volumes Gas transfer Bronchial chalenge

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What is a spirometry ??
Spirometry is a measure of airflow and lung volumes during a forced expiratory maneuver from full inspiration

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How to do it ??

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1. Stand or sit up straight (The patient places a clip over the nose ) 2. Inhale maximally 3. Get a good seal around mouthpiece of the spirometer 4. Blow out as hard as fast as possible and count for at least 6 seconds. 5. Record the best of three trial
*pt should hold bronchodilator few hrs before the test
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1. Volume Time Graph

2. Flow-volume loops Flow-

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Volume Time Graph The volume is plotted against the time, it displays the expiration.

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1. FVC 2. FEV1 FEV1 3. FEV1/FVC FEV1 4. FEF25% FEF25% 5. FEF75% FEF75%

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Forced Vital Capacity (FVC) The total amount of air expired as quickly as possible after taking the deepest possible breath.

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FEV1 : Volume of air which can be forcibly exhaled from the lungs in the first second of a forced expiratory maneuver.

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FEV1 FEV1/FVC
Ratio of FEV1 to FVC : FEV1 It indicates what percentage of the total FVC was expelled from the lungs during the first second of forced exhalation This value is critically important in the diagnosis of obstructive and restrictive diseases

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FEF25%
Amount of air that was forcibly expelled in the first 25% of the total forced vital capacity test.

FEF75%
The amount of air expelled from the lungs during the first (75%) of the forced vital capacity test.

FEF25%FEF25%-75%
The amount of air expelled from the lungs during the middle half of the forced vital capacity test.

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FlowFlow-volume loops

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FlowFlow-volume loops  Is a plot of inspiratory and expiratory flow in the vertical axis against volume in the horizental axis, during the performance of maximally forced inspiratory and expiratory maneuvers.
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The contour of the loop assists in the diagnosis and localization of airway obstruction as different lung disorders produce distinct ,easily recognized pattern.

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Useful also in assesing acceptability of the manoeuvers: 1. Lack of early peak suggest poor effort. 2. Sudden tailing off of expiration curve suggest that the patient stopped blowing too early 3. Cough

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Obstructive V/S restrictive lung disease ???

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Obstructive Lung Diseases

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Common Obstructive Lung Diseases  Asthma  COPD (chronic bronchitis, emphysema and
the overlap between them).


Cystic fibrosis.

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-Airflow is reduced because the airways narrow and the FEV1 is FEV1 reduced -Spirogram may continue to rise for more than 6 seconds because lung take longer to empty -FVC may also be reduced because gas is trapped behind obstructed bronchi due to increase in intrathoracic pressure during maneuver compresses airways causing early airway closure and gas trapping but this reduction to a lesser extent than FEV1 FEV1

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FEV1 80% of predicted Normal FEV1 60-80% 60of predicted mild obst. FEV1 40-60% 40of predicted moderate FEV1 40% of predicted severe The cardinal feature is FEV1/FVC ratio If the ratio less than 70 consider obstructed disease .
*Predictors: Sex, Age, Ht

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Predictors: Sex, Age, Ht ??

The measurements are related to the following factors:

Age : FVC and flow rates decline with age. The value of FVC increases up to 24 years of age and remain stable to age 35. Height : All spirometric measurements increase with body weight. It is due to an increase in number and/or size of alveoli relative to airways, the larger lungs are likely to take longer than smaller one. Sex : Most pulmonary function values are lower in female than male. Weight : A spirometric results are positively correlated with weight to the extent that increased weight means growth or muscle mass. Beyond this (in obesity) spirometric values (and lung values specially ERV) decrease with greater weight.

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Flow volume loop in Obstructive lung disease

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Asthma
 Peak expiratory flow reduced so maximum height of the loop is reduced  Airflow reduces rapidly with the reduction in the lung volumes because the airways narrow and the loop become concave  Concavity may be the indicator of airflow obstruction and may present before the change in FEV1 FEV1 FEV1 or FEV1/FVC

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Emphysema
Airways may collapse during forced expiration because of destruction of the supporting lung tissue causing very reduced flow at low lung volume and a characteristic (dog(dog-leg) appearance to the flow volume curve

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Reversibility


Improvement in FEV1 by 121215% or 200 ml in repeating spirometry after treatment with Sulbutamol 2.5mg or ipratrobium promide by nebuliser after 15-30 15minutes Reversibility is a characterestic feature of B.Asthma In chronic asthma there may be only partial reversibility of the airflow obstruction While in COPD the airflow is irriversible although some cases showed significant improvement.
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Interpretation of PFTs
Step 1. Look at the Flow-Volume loop to determine Flowacceptability of the test, and look for upper airway obstruction pattern. pattern. Step 2. Look at the FEV1 to determine if it is normal ( FEV1 80% predicted). 80% predicted). Step 3. Look at FVC to determine if it is within normal limits ( 80%). 80% Step 4. Look at the FEV1/FVC ratio to determine if it is FEV1 within normal limits ( 70%). 70%

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Step 5. Look at FEF25-75% (Normal ( FEF25-75%



60%) 60%

If FEV1, FEV1/FVC ratio, and FEF25-75% all are FEV1 FEV1 FEF25-75% normal, the patient has a normal PFT. PFT. If both FEV1 and FEV1/FVC are normal, but FEF25FEV1 FEV1 FEF2575% 75% is 60% ,then think about early obstruction or 60% small airways obstruction. obstruction.

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If FEV1 FEV1 obstructive obstruction. obstruction. restriction is

80% and FEV1/FVC 80% FEV1 70%, there is 70% defect, if FVC is normal, it is pure 80% , possibility of additional 80% If FVC there. there.

If FEV1 FEV1 80% , FVC 80% 80% and FEV1/FVC 80% FEV1 70% , 70% there is restrictive defect, get lung volumes to confirm. confirm.

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Examples

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Mild Obstructive Defect with good response to bronchodilator Diagnosis:

B.Asthma

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A 66 year old female complains of cough after dust exposure

Meas FVC FEV1 FEV1 FEV1 FEV1/FVC FEF 25-75 25PEF 2.2 1.79 81 1.82 5.67

Ref 2.58 1.85 72 2.23 5.2

%Pred 85 97

82 109
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Normal Spirometry

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Flow volume loop suggestive of obstructive disease Spirometry showed Severe Obstructive defect with no response to bronchodilator Increased FVC could be because of Airtrapping or could be combined obstructive and restrictive defect to confirm need to do Lung Volume diagnosis :

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

Meas FVC FEV1 FEV1 FEV1 FEV1/FVC FEF25FEF25-75 PEF 2.62 1.45 55 0.43 4.50

Ref 2.82 1.98 69 2.20 5.48

%Pred 93 72

20 82
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Mild Obstructive defect

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Large Airway Obstruction

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1. Fixed obstruction 2. Variable extrathoracic obstruction 3. Variable intrathoracic obstruction

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Flow Volume Loop in Large Airway Obstruction

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Fixed obstruction
1. 2. 3. 4. Post intubation stenosis Goiter Endotracheal neoplasms Bronchial stenosis Maximum airflow is limited to a similar extent inspiration in both inspiration and expiration expiration

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Variable extrathoracic extrathoracic Obstruction

1. Bilateral and unilateral vocal cord paralysis 2. Vocal cord constriction 3. Reduced pharyngeal crosscrosssectional area 4. Airway burns

The obstruction worsens in inspiration inspiration because the negative pressure narrows the trachea and inspiratory flow is reduced to a greater extent than expiratory flow
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In variable intrathoracic intrathoracic obstruction 1. Tracheomalacia

2. Polychondritis 3. Tumors of the lower trachea or main bronchus. The narrowing is maximal in expiration expiration because of increased intrathoracic pressure compressing the airway. The flow volume loop shows a greater reduction in the expiratory phase
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Small Airways obstruction



Diseases affecting primarily the small (peripheral) airways can be extensive yet not affect the FEV1(e.g. FEV1(e. early COPD, interstitial granulomatous disorders). disorders). Small airways status is reflected by the FEF25-75% FEF25-75% (mid(mid-range flow), best determined from the flowflowvolume loop. loop. Some patients have normal spirometry with the exception of a reduced FEF25-75%, this is suggestive FEF25-75% of possible small airways dysfunction and potentially early obstruction. obstruction.
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Example

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A 38 year old female complains of wheezing on exertion

Meas FVC FEV1 FEV1 FEV1 FEV1/FVC FEF25FEF25-75 PEF

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Ref 3.54 2.77 78 4.20 6.25

%Pr e d 103 83 51 38
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3.66 2.30 63 2.15 2.39

Flow volume loop suggests a fixed upper airway obstruction

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Effect of Smoking:


Smoking in patients with COPD is associated 90with decline in FEV1 of 90-150 mL/year Smoking cessation is (associated with increase in FEV1 for first year) followed with a decline of only 30 mL/year

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Restrictive Lung Diseases

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A. Intrinsic Restrictive Lung Disorders

1.
2.

Sarcoidosis Idiopathic pulmonary fibrosis Interstitial pneumonitis Tuberculosis Pnuemonectomy (loss of lung) Pneumonia

3. 4. 5. 6.

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B. Extrinsic Restrictive Lung Disorders

1.
2. 3. 4. 5. 6. 7. 8.

Scoliosis, Kyphosis Ankylosing Spondylitis Pleural Effusion Pregnancy Gross Obesity Tumors Ascites Pain on inspiration - pleurisy, rib fractures

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C. Neuromuscular Restrictive Lung

Disorders
1. 2. 3. 4. 5. 6.

Generalized Weakness malnutrition Paralysis of the diaphragm Myasthenia Gravis Muscular Dystrophy Poliomyelitis Amyotrophic Lateral Sclerosis

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Full expantion of the lung is limited and therefore the FVC is reduced FEV1 FEV1 may be reduced because the stiffness of fibrotic lungs increases the expiratory pressure FEV1 FEV1/FVC will be Normal or Increased

*if you suspect restrictive pattern you must check TLC

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Flow volume loop in Restrictive lung disease

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Flow volume loop in Restrictive lung disease :

 Full lung expantion is prevented by fibrotic tissue in the lung parenchyma and the FVC is reduced .  Elastic recoil may increased by fibrotic tissue lead to increase the airflow  Both FEV1 and FVC may be reduced because the lungs are small and stiff ,but the peak expiratory flow may be preserved or even higher than predicted leads to tall,narrow and steep flow volume loop in expiratory phase.

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Example

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Mild restrictive defect suggested by reduced in FVC with normal to high FEV1/FVC Need lung volume and diffusion capacity to assess if it is intrinsic or extrinsic type

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Obstructive & restrictive defects

Parameter Obstruction Restriction FEV1 FEV1 Reduced Reduced FVC Normal Reduced Normal FEV1 FEV1/FVC Reduced

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Acceptability and Reproducibility Criteria

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Acceptability Criteria free from artifacts:  Cough or glottis closure during the first second of exhalation  Eary termination or cutoff  Variable effort  Leak  Obstructed mouthpiece  Have good starts  Have a satisfactory exhalation 6 s of exhalation

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Reproducibility Criteria After 3 acceptable spirograms been obtained

 Are the two largest FVC within 0.2 L of each other?  Are the two largest FEV1 within 0.2 L of each other?
If both of these criteria are met, the test session may be concluded. If both of these criteria are not met, continue testing until Both of the criteria are met with analysis of additional acceptable spirograms; OR a total of eight tests have been performed
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Acceptability of the test

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Normal Early Glottic Closure

Cough
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Poor Effort

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Example

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1.What is the defect?

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Mild obstructive defect with good response to bronchodilator Diagnosis

B.Asthma

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