:Introduction

Pulmonary function tests are series of tests that evaluate how well the lungs work .The
tests provide information about the total amount of air a person's lungs can hold, how
much air a person inhales at a breath, how quickly the lungs can move air in and out,
and how well the gases diffuse into (and out from) the blood stream .

The pulmonary function tests can be used to :

1- Screen for or diagnose lung diseasese.g .abnormal blood flow to the lungs
(pulmonary hypertension), COPD (chronic bronchitis and emphysema), reactive airway disease
(asthma), and others (cystic fibrosis and pulmonary fibrosis), etc

2- Categorize the different types of lung processes (restrictive vs. Obstructive) .

3- Differentiate between two common and look-alike diseases (asthma vs COPD).
4- Assess and evaluate the lung disease severity (COPD, sarcoidosis, asthma, etc)..
5- Follow the progression of the lung disease, for example, does the patient need
lung transplant or not? If he has severe progressive disease, which is evaluated by
the objective PFTs, then lung transplant might be considered.
6- Check how well treatment for a lung disease is working; to measure the
efficacy of treatment; once a respiratory problem has been diagnosed, pulmonary
function tests can be used to monitor response to treatment.
7- For preoperative assessment; to evaluate the operative risk, they determine
whether the patient qualifies for the surgery/operation or not? PFTs determine
whether a patient with lung cancer has enough lung reserve to withstand the
surgical removal of the lung or part of lung that contains the cancer. Some
patients have borderline lung function, which is evaluated by the PFTs, so doing a
lobectomy/surgery for these patients is such a dangerous decision.

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Lung Volumes
Total Lung Capacity (TLC): it is the amount of air present in the lung after the

end of maximal/deep inspiration .It equals Vital Capacity +Residual Volume. It is

decreased in patients with restrictive lung diseases (lung inflammation &/or
fibrosis, kyphoscoliosis, and in those who have done lobectomy), where these
diseases/conditions limit the amount of air inspired and lead to progressive loss of
lung volume with normal expiration .
Residual Volume (RV): it is the amount of air that remains in the lungs at the end
of maximal expiration, is stable, non-mobile, and unusable .It is increased in
patients with obstructive lung diseases (lung hyper-inflation or hyper-expansion
like in patients with COPD, asthma, & bronchiectasis), where these diseases
tend to limit the volume which can be expired, either due to airways
narrowing/obstruction or parenchymal destruction (loss of elastic recoil.)
Vital Capacity (VC): discussed later in this lecture .It is defined as the usable
lung volume .It equals Total Lung Capacity - Residual Volume .It is decreased in
obstructive & restrictive lung diseases.

Now we will go to the mechanical assessment of the lung, you can assess it by
spirometry, you can ask about lung volumes, or you can ask about diffusion capacity
of the carbon monoxide (DLCO), we will talk about them one by one:

Spirometry:
The only of what we do is a dynamic process, the patient take a breath "inhale and
exhale", then we measure two things;
1 Volume

2 flow "speed"

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So we say to the patient to take a maximum inspiratory volume to the total lung
capacity, then exhale until you cant exhale more" until the residual volume", and
then we measure the volume and the flow of the patient, it has to be at full effort,
and we have to do at least 3 tests.
If you look at a spirometry results you will see a lot of numbers, but what concern us
is two numbers which are FEV1 and FVC, and also you should notice the ratio
between them FEV1\FCV.
Remember that this maneuver done at extreme force, you told the patient to take
deep breath and then exhale forcefully until the residual volume, so it is a forced
maneuver.

FVC:
Forced vital capacity =total lung capacity residual volume
(FVC =TLC RV)

FEV1:
We have a mer that will measure to us how much volume will be exhaled in 1
second, so this is time limiting step, the patient who have COPD and airway
narrowing, he cant exhale a large volume of air in 1 second, so the FEV1 will be
decreased in these patients, so this is one of the markers of obstructive lung
diseases.
They found that we can divide FEV1/FVC of the patient; usually normal people can
exhale more than 80 %of their lung volume in one second.

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This curve you might take it in physiology in time and volume, but here we do it in
time, volume and flow, the shape of this curve is important
So this person takes a deep breath to the total lung
capacity, and then starts to exhale to the residual
volume, so the difference between them is FVC,
and it is around 5.6 liters in this person .
If the patient has restrictive lung disease what will
happen to the volume? It will decrease.
The flow means the speed of air exhaled, and the
best speed always at the beginning, so at first
exhalation will be at peak flow and then decreased
until it reached zero.
So this is a normal graphic illustration of the flow and volume.
Now we will look at the abnormal shapes" :see notes about these shapes in the
next page"

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1-In the first shape the patient will get out the flow and then keep it constant, and then decreased,
the same thing with inhalation, so these patients have fixed upper airway obstruction, like patients
with tracheal tumors.
2-Intrapulmonary obstruction like emphysema, the fixed will be in the expiratory part.
3-Extra-thoracic bronchial obstruction, like when the thyroid pushing on the trachea from outside.
4 -Intra-thoracic bronchial obstruction.
So these shapes give the diagnosis sometimes from just looking at them.
These shapes usually come in the exams.

The Spirometry Normal Values you may wonder where they came from?
Well the normal values are derived from normal subjects Based on population with
similar age, race, gender, and height NOT the weight.

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Please look at the slide above and note that if the rate of the TLC, RV is more than
120 % that means that there is air trapping.
The Reproducibility test means when the patient repeats the test, the all the curves in
the tests have to be almost symmetrical with minor variations, usually the machine
will pick the best curve its self.

We have two patterns in the pulmonary function test

1. Normal
2. Abnormal result usually indicates the presence of some degree of obstructive
lung disease such as asthma, emphysema or chronic bronchitis, or restrictive
lung disease such as pulmonary fibrosis or chest wall deformities.
Obstructive lung disease that blocks breathing :
The most important clue about it, is the decrease in the FEV1/FVC ratio
below 70%.
Usually the FEV1 is signicantly decreased but the FVC might be normal or
decreased.
The shape of the curve in the Obstructive Pattern is Concave flow volume
loop.
Some examples about the obstructive pattern E.g .Asthma, COPD,
bronchiectasis
restrictive lung diseases that limit the expansion and capacity of the lungs
:
We have two causes of the restrictive lung diseases:
The Intrinsic lung diseases :its caused by the interstitial lung diseases in
general.
The Extrinsic causes or Extrapulmonary causes means "outside the lungs ".
The lungs are usually normal, but their expansion is limited .This reduces the
air volume and the capacity to take air in.

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Impaired expansion makes it difficult for the lungs to maintain sufficient air exchange .
Some Thoracic cage abnormalities (chest wall deformities, kyphosis or Pickwickian
syndrome) cause Extrinsic restrictive lung diseases

In the restrictive lung diseases The whole values are decreased the Forced vital
capacity (FVC), the Forced expiratory volume in one second (FEV1) and the monoxide
Diffusing Capacity (DLCO).
But the FEV1 / FVC ratio may be normal or even increased as a result of decreased lung
compliance in contrast to obstructive lung disease where this ratio is reduced.

**This is a graphical illustration of what we have said

In normal people.RV is 20 %of TLC and the
rest of course is VC.
In restrictive diseases.all these values "VC,
RV, TLC "decrease.
And in obstructive diseases.although there is
increase in the TLC, but this increase occurs in
the RV only "which is useless lung volume, on
the other hand we have decrease in the VC .

***in the slides, we have 2 pictures about the pulmonary function tests equipments, for

those who are interested in technology.

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##now,

Dr .said that we "as 4th year medical students "should only differentiate whether the
case is normal, obstructive or restrictive .And it isn't imp .for us to assess the severity .
For differentiation, we are interested in three values, and those are FEV1\FVC ratio,
FVC and FEV1, in the following discussion, we will learn how to use these values to
differentiate between the three different situations.
***firstly, we see the FEV1\FVC ratio, if it's >70% , then we have either 1normal case or
2restrictive case , then we use FVC to know whether this is normal or restrictive case, if
FVC is normal, then this is normal case, while if FVC is decreased then this restrictive
case.
now suppose we have restrictive case how to assess the severity?? we use TLC to do
that.as the following:

80 %is considered normal

65-80 %is considered mild

50-65 %is considered moderate

<50 %is considered severe

***let's go back to the FEV1\FVC rationow, if it's <70%, then this is obstructive
surely, then you have to assess the severityand here we use FEV1 to do that
80 %is considered normal
65-80 %is mild
50-65 %is moderate
30-50 %is severe
<30 %is very severe
**dr .again said that we should know the type of the case only, the severity isn't that imp for us.

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---this is a graphical summary of what we have said, you should be aware of the

adequacy of the study at the beginning, means that you should have good situation,
posture,.etc.

Restrictive lung disease:

Remember this statement :Reduced TLC is the GOLD standard to
define restrictive ventilatory defect.
Measurements of lung volumes (TLC, RV )are needed.
So to say it is restrictive or lung fibrosis we must look at the TLC, the measurement of
TLC is more sophisticated than spirometry, so the small device is not usable in this
case because it couldn't measure the residual volume, thus TLC is recommended only
when the volumes are suggestive to do it, and there is special devices used to
measure the residual volume such as the box bellow & inhaling delusion .

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So it is expensive, time consuming and only order if you suspect restrictive or

interstitial lung disease.

Diffusing Capacity of carbon monoxide (DLCO):

Measures the ability of the lung to transfer gas from the

environment to the bloodstream
Measures the volume of gas that moves across the alveolarcapillary barrier
Our lungs are naive for carbon monoxide, so if I asked you to inhale a percent
volume of carbon monoxide it will diffuse quickly to the blood because it is a highly
diffusible gas and it will attach to hemoglobin and as you know from your physiology
the compota on in which carbon monoxide binds 200 mes more than oxygen to
hemoglobin.

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So we put a volume of carbon dioxide and then we let the patient breathe for a
while after that we measure the coming back volume, so the decreased volume
gone to the blood, if you are healthy carbon monoxide will diffuse easily but if there
is a problem in the diffusion membrane such as lung fibrosis carbon monoxide will
not penetrate.

These values are not important as the doctor said:

Normal is considered 75.%
Less than 75 %is reduced.
Less than 40%
Commonly associated with resting or exercise
induced hypoxemia.
Decreased DLCO
Anemia, because there is no hemoglobin.
Emphysema "sensitive", it is a destruction of the gas exchange it
looks like a honey comb appearance so there will be like holes.
Pulmonary vascular disease because there is no blood supply from
the right side to the lung.
Interstitial lung diseases "sensitive "Sarcoid, lung fibrosis,
Increased DLCO
Heart failure because there is an increase in blood flow to the
lungs.
Alveolar hemorrhage because if there is blood in the alveoli it will
take the carbon monoxide so carbon monoxide went to the blood
not through the circulation but directly to the accumulated blood
inside the alveoli.
Bronchial asthma.
Q: DOES PULMONARY EDEMA INCREASE OR DICREASE THE DLCO?
THE DOCTOR ANSWERED: it INCREASES THE DLCO.

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PFT summary:
Check the study to make sure it is adequate
Obstructive ventilatory defect
o Dened by FEV1/FVC <70%
o Severity is graded by FEV1
Restrictive ventilatory defect
o Reduced FVC with no obstruction suggests the presence of a
restrictive deficit.
o Defined and confirmed by reduced TLC.

....

NOW how we differentiate between ASTHMA and COPD.

The principle is to do the spirometry for those pts then give them a bronchodilator
"salbutamol" and do the spirometry again, so if there is improvement in the FEV1 > 15 %
after giving the bronchodilator this suggest ASTHMA more than COPD .

The cut point

If we make the cut point for FEV1 10%; then we will shift a lot of COPD pts to be an
asthmatic pts .And if we make the cut point for FEV1 20% then we do the opposite
)asthma to COPD.)So as a role consider the number as 15%.........OK.

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Examples:

This PFT shows the gender, age, height "in", weight "Ib"el jehaz made in USA .When
we want to analyze any PFT we do the following:
We look first at FEV1/FVC ratio which is 83% and that means normal.
Then we look at FVC which is 90% and that means normal.

So this is a normal slidetmam

NOTE :the PRED means the predicted value for the pt with certain values "height,
weight, ageetc."
Another example:

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This pt is male, 48 years old, height 67 inch, weight 262 Ib

Look at the FEV1/FVC ratio which is 66%

obstructive, and to determine

the severity look at the FEV1 which is 65%. So its a mild obstruction "6580 ".
Then after giving the salbutamol the FEV1 changed from 2.22 to 2.45 and
the ratio is 10 "<15%", so its most likely COPD.

Notice that the improvement in

the curve is not that big.

So this is copd.
Another example:

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This pt is male, 49 years old, height 70 inch, weight 211 Ib .the PFT
results as the following:
The FEV1/FVC ratio is 52 % which means obstruction .And according
to the severity FEV1= 63 % which means moderate obstruction "5065."
Then we look at the FEV1 which is 17% "changed from 2.34 to 2.76 "
so its reversible obstruction.

Here you can notice the big change

in the curve!!

so THIS IS ASTHMA
THE END
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THE BEST VOCAL CORDS EVER
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inspection before doing the operation ; (the result is 2-1 for us
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special tnx for mohammad ezzat+anwar salamopotta talamacasse aba khaba I am doing
well in Malaysian language so I am looking forward to be fluent in ur language after I
graduate so I will speak Arabic, English, French, and Malaysian.

DR.OMAR AL MOLQE IT WAS A NICE ROUND WITH U FOR A9 IN AMMAN

Finally my brother LAITH 3ANANII MISS U A LOT & THE GENTEL MAN HANI

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