PULMONARYFUNCTIONTESTS

INTRODUCTION

Pulmonaryfunctiontestsisagenerictermusedto
indicateabatteryofstudiesormaneuversthatmay
beperformedusingstandardizedequipmentto
measurelungfunction.
Evaluatesoneormoreaspectsoftherespiratory
system
Respiratorymechanics
Lungparenchymalfunction/Gasexchange
Cardiopulmonaryinteraction
 INDICATIONS

DIAGNOSTIC PROGNOSTIC
Evaluationofsigns&symptoms Assessseverity
BLN,chronic cough,exertional
dyspnea
Screeningatriskpts Followresponsetotherapy
MeasuretheeffectofDs on Determinefurthertreatmentgoals
pulmonaryfunction
To assesspreoperativerisk Evaluatingdegreeofdisability
Monitorpulmonarydrugtoxicity
 TISIGUIDELINES
Age>70
Obesepatients
Thoracicsurgery
Upperabdominalsurgery
Historyofcough/smoking
Anypulmonarydisease
 AmericanCollegeofPhysicians
Guidelines
Lungresection
H/osmoking,dyspnoea
Cardiacsurgery
Upperabdominalsurgery
Lowerabdominalsurgery
Uncharacterizedpulmonarydisease(definedashistoryof
pulmonaryDiseaseorsymptomsandnoPFTinlast60days)
 Contraindications
Recenteyesurgery
Thoracic,abdominalandcerebralaneurysms
Activehemoptysis
Pneumothorax
Unstableangina/recentMIwithin1month
 INDEX

1. CategorizationofPFTs
2. Bedsidepulmonaryfunctiontests
3. Staticlungvolumesandcapacities
4. MeasurementofFRC,RV
5. Dynamiclungvolumes/forcedspirometry
6. Physiologicaldeterminantofspirometry
7. Flowvolumeloopsanddetectionofairwayobstruction
8. Flowvolumeloopandlungdiseases
9. Testsofgasexchangefunction
10. Testsforcardiopulmonaryreserve
11. Preoperativeassessmentofthoracotomypatients
 CATEGORIZATIONOFPFT

MECHANICALVENTILATORY
FUNCTIONSOFLUNG/CHESTWALL:

BEDSIDEPULMONARYFUNCTIONTESTS
STATICLUNGVOLUMES&CAPACITIES VC,IC,IRV,
ERV,RV,FRC.
DYNAMICLUNGVOLUMESFVC,FEV1,FEF2575%,
PEFR,MVV,RESP.MUSCLESTRENGTH
GAS EXCHANGETESTS:

A)Alveolararterialpo2gradient
B)Diffusioncapacity
C)Gasdistributiontests 1)singlebreathN2
test.2)MultipleBreathN2 test3)Heliumdilution
method4)RadioXe scinitigram.
CARDIOPULMONARYINTERACTION:

Qualitativetests:
1)History,examination
2)ABG
Quantitativetests
1)6minwalktest
2)Stairclimbingtest
3)Shuttlewalk
4)CPET(cardiopulmonaryexercisetesting)
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 Bed side pulmonary function tests

RESPIRATORY RATE

Essentialyetfrequentlyundervalued
componentofPFT
Impevaluatorinweaning&extubation
protocols

IncreaseRR musclefatigue workload weaningfails

 Bed side pulmonary function tests

1) Sabrasezbreathholdingtest:
Askthepatienttotakeafullbutnottoodeepbreath&hold
itaslongaspossible.
>25SEC.NORMALCardiopulmonaryReserve(CPR)
1525SEC LIMITEDCPR
<15SEC VERYPOORCPR(Contraindicationfor
electivesurgery)
25 30SEC 3500mlVC
20 25SEC 3000mlVC
15 20SEC 2500mlVC
10 15SEC 2000mlVC
5 10SEC 1500mlVC
 Bed side pulmonary function tests

2)SCHNEIDERSMATCHBLOWINGTEST:MEASURESMaximum
BreathingCapacity.
Asktoblowamatchstickfromadistanceof6(15cms)
with
Mouthwideopen
Chinrested/supported
Nopurselipping
Noheadmovement
Noairmovementintheroom
Mouthandmatchatthesamelevel
 Bed side pulmonary function tests

Cannotblowoutamatch
MBC<60L/min
FEV1<1.6L
Abletoblowoutamatch
MBC>60L/min
FEV1>1.6L
MODIFIEDMATCHTEST:
DISTANCEMBC
9>150L/MIN.
6>60L/MIN.
3>40L/MIN
 Bed side pulmonary function tests

3)COUGHTEST:DEEPBREATHF/BYCOUGH
ABILITYTOCOUGH
STRENGTH
EFFECTIVENESS
INADEQUATECOUGHIF:FVC<20ML/KG
FEV1<15ML/KG
PEFR<200L/MIN.

*Awetproductivecough/selfpropagatedparaoxysmsof
coughing patientsusceptibleforpulmonaryComplication.
 Bed side pulmonary function tests

4)FORCEDEXPIRATORYTIME:
Afterdeepbreath,exhalemaximallyandforcefully&keep
stethoscopeovertrachea&listen.
NFET 35SECS.
OBS.LUNGDIS. >6SEC
RES.LUNGDIS. <3SEC
 Bed side pulmonary function tests

5)WRIGHTPEAKFLOWMETER:MeasuresPEFR(PeakExpiratory
FlowRate)
N MALES 450700L/MIN.
FEMALES 350500L/MIN.
<200L/MIN. INADEQUATECOUGHEFFICIENCY.
6)DEBONOWHISTLEBLOWINGTEST:MEASURESPEFR.
Patientblowsdownawideboretubeattheendofwhichisa
whistle,onthesideisaholewithadjustableknob.
Assubjectblowswhistleblows,leakholeisgradually
increasedtilltheintensityofwhistledisappears.
Atthelastpositionatwhichthewhistlecanbeblown,the
PEFRcanbereadoffthescale.
DEBONOSWHISTLE
 Bed side pulmonary function tests

MICROSPIROMETERS MEASUREVC.

BEDSIDEPULSEOXIMETRY

ABG.
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 STATIC LUNG VOLUMES AND
CAPACITIES

SPIROMETRY:CORNERSTONEOFALLPFTs.
Johnhutchinson inventedspirometer.
Spirometryisamedicaltestthatmeasuresthe
volumeofairanindividualinhalesorexhalesasa
functionoftime.
CANTMEASURE FRC,RV,TLC
 SPIROMETRYAcceptabilityCriteria

Goodstartoftest withoutanyhesitation
Nocoughing/glotticclosure
Novariableflow
Noearlytermination(>6sec)
Noairleak
Reproducibility Thetestiswithoutexcessivevariability
ThetwolargestvaluesforFVCandthetwolargestvaluesfor
FEV1 shouldvarybynomorethan0.2L.
SPIROMETRYAcceptabilityCriteria
 SpirometryInterpretation:Sowhat
constitutesnormal?

Normalvaluesvaryanddependon:
I. Height Directlyproportional
II. Age Inverselyproportional
III. Gender
IV. Ethnicity
LUNGVOLUMESANDCAPACITIES

PFTtracingshave:
FourLungvolumes:tidal
volume,inspiratory reserve
volume,expiratoryreserve
volume,andresidualvolume

Fivecapacities:inspiratory
capacity,expiratorycapacity,
vitalcapacity,functionalresidual
capacity,andtotallungcapacity

Additionof2ormorevolumescompriseacapacity.
 LUNGVOLUMES
TidalVolume (TV):volumeof
airinhaledorexhaledwith
eachbreathduringquiet
breathing(68ml/kg)500ml
InspiratoryReserveVolume
(IRV):maximumvolumeofair
inhaledfromtheend
inspiratorytidalposition.3000
ml
ExpiratoryReserveVolume
(ERV):maximumvolumeof
airthatcanbeexhaledfrom
restingendexpiratorytidal
position.1500ml
 LUNGVOLUMES

ResidualVolume(RV):
Volumeofairremainingin
lungsaftermaximium
exhalation(2025ml/kg)
1200ml
Indirectlymeasured(FRC
ERV)
Itcannotbemeasuredby
spirometry.
 LUNGCAPACITIES
TotalLungCapacity (TLC):Sumof
allvolumecompartmentsor
volumeofairinlungsafter
maximuminspiration(46L)
VitalCapacity(VC):TLCminusRV
ormaximumvolumeofair
exhaledfrommaximalinspiratory
level.(6070ml/kg)5000ml. VC~
3TIMESTVFOREFFECTIVE
COUGH
Inspiratory Capacity (IC):Sumof
IRVandTVorthemaximum
volumeofairthatcanbeinhaled
fromtheendexpiratorytidal
position.(24003800ml).
ExpiratoryCapacity(EC):TV+ERV
 LUNGCAPACITIES
FunctionalResidualCapacity
(FRC):
SumofRVandERVorthe
volumeofairinthelungsat
endexpiratorytidal
position.(3035ml/kg)2500ml
Decreases
1.insupineposition(0.51L)
2.Obesepts
3.Inductionofanesthesia:by16
20%
 FUNCTIONOFFRC

Oxygenstore
Bufferformaintainingasteadyarterialpo2
Partialinflationhelpspreventatelectasis
Minimizestheworkofbreathing
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 Measuring RV, FRC

Itcanbemeasuredby
nitrogenwashouttechnique
Heliumdilutionmethod
Bodyplethysmography
 N2 Washout Technique

Thepatientbreathes100%oxygen,andallthe
nitrogeninthelungsiswashedout.
Theexhaledvolumeandthenitrogen
concentrationinthatvolumearemeasured.
Thedifferenceinnitrogenvolumeattheinitial
concentrationandatthefinalexhaled
concentrationallowsacalculationof
intrathoracicvolume,usuallyFRC.
 Helium Dilution technique

Ptbreathesinandoutfromareservoirwithknown
volumeofgascontainingtraceofhelium.
Heliumgetsdilutedbygaspreviouslypresentinlungs.
eg:if50mlHeliumintroducedandthehelium
concentrationis1%,thenvolumeofthelungis5L.
 Body Plethysmography

Plethysmography (derivedfromgreek wordmeaning

enlargement).

BasedonprincipleofBOYLESLAW(P*V=k)
Priniciple advantageoverothertwomethodisit
quantifiesnon communicatinggasvolumes.
 Apatientisplacedinasitting
positioninaclosedbodybox
withaknownvolume
Thepatientpantswithan
openglottisagainstaclosed
shuttertoproducechanges
intheboxpressure
proportionatetothevolume
ofairinthechest.
Asmeasurementsdoneat
endofexpiration,ityields
FRC
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
FORCEDSPIROMETRY/TIMEDEXPIRATORY
SPIROGRAM

Includesmeasuring:
pulmonarymechanics to
assesstheabilityofthelungto
movelargevol ofairquickly
throughtheairwaystoidentify
airwayobstruction
FVC
FEV1
SeveralFEFvalues
Forcedinspiratory rates(FIFs)
MVV
 FORCEDVITALCAPACITY

TheFVCisthemaximumvolumeofairthatcanbe
breathedoutasforcefullyandrapidlyaspossible
followingamaximuminspiration.
CharacterizedbyfullinspirationtoTLCfollowedby
abruptonsetofexpirationtoRV
Indirectlyreflectsflowresistancepropertyof
airways.
FORCEDVITALCAPACITY
 FVC

Interpretation of % predicted:
80-120% Normal
70-79% Mild reduction
50%-69% Moderate reduction
<50% Severe reduction

FVC
 MeasurementsObtainedfromtheFVC
Curveandtheirsignificance

Forcedexpiratoryvolume
in1sec(FEV1 )the
volumeexhaledduring
thefirstsecondofthe
FVCmaneuver.
Measuresthegeneral
severityoftheairway
obstruction
Normalis34.5L
 MeasurementsObtainedfromtheFVC
Curveandtheirsignificance

FEV1 Decreasedinbothobstructive&restrictivelung
disorders(ifpatientsvitalcapacityissmallerthanpredicted
FEV1).
FEV1/FVC Reducedinobstructivedisorders.
Interpretationof%predicted:
>75% Normal
60%75% Mildobstruction
5059% Moderateobstruction
<49% Severeobstruction
MeasurementsObtainedfromtheFVC
Curveandtheirsignificance
 Forcedmidexpiratory flow2575%(FEF25
75)

Max.Flowrateduringthe
midexpiratorypartofFVC
maneuver.
MeasuredinL/sec
Mayreflecteffort
independentexpiration
andthestatusofthesmall
airways
Highlyvariable
DependsheavilyonFVC
Nvalue 4.55l/sec.Or300
l/min.
Forcedmidexpiratory flow2575%(FEF25
75)

Interpretationof%predicted:
>60% Normal
4060%Mildobstruction
2040%Moderateobstruction
<10% Severeobstruction
 Peakexpiratoryflowrates

MaximumflowrateduringanFVCmaneuveroccursininitial
0.1sec
Afteramaximalinspiration,thepatientexpiresasforcefully
andquicklyashecanandthemaximumflowrateofairis
measured.
Forcedexpiratoryflowbetween2001200mlofFVC
Itgivesacrudeestimateoflungfunction,reflectinglarger
airwayfunction.
Effortdependantbutishighlyreproductive
 Peakexpiratoryflowrates
Itismeasuredbyapeakflowmeter,
whichmeasureshowmuchair(litres
perminute)isbeingblownoutorby
spirometry
The peak flow rate in normal adults
varies depending on age and height.
Normal : 450 700 l/min in males
300 500 l/min in females
Clinicalsignificance valuesof<200/l
impairedcoughing&hencelikelihood
ofpostopcomplication
 MaximumVoluntaryVentilation(MVV)or
maximumbreathingcapacity(MBC)

Measures speedandefficiencyoffilling&
emptyingofthelungsduringincreasedrespiratory
effort
Maximumvolumeofairthatcanbebreathedinand
outofthelungsin1minutebymaximumvoluntary
effort
Itreflectspeakventilation inphysiologicaldemands
Normal:150175l/min.ItisFEV1*35
<80% grossimpairment
 MaximumVoluntaryVentilation(MVV)or
maximumbreathingcapacity(MBC)
Thesubjectisaskedtobreatheas
quicklyandasdeeplyaspossible
for12secs andthemeasured
volumeisextrapolatedto1min.
Periodslongerthan15seconds
shouldnotbeallowedbecause
prolongedhyperventilationleads
tofaintingduetoexcessive
loweringofarterialpCO2 andH+.
MVVismarkedlydecreasedin
patientswith
A. Emphysema
B. Airwayobstruction
C. Poorrespiratorymusclestrength
TOSUMMARISE
PHYSIOLOGICALDETERMINANTSOFMAX.
FLOWRATES

1)DEGREEOFEFFORT drivingpressuregeneratedbymuscle
contraction(PEmax&PImax)
2) ELASTICRECOILPRESSUREOFLUNG:(PL)
Tendencytorecoilorcollapsed/tPL
PLincreasesfromRV(23)toTLC(2030)
OpposedbyPcw(recoilpr.Ofchestwall)
Prs=Pl+Pcw=0atFRCrestingstate
(Prsrecoilpr.ofresp.system)
3)AIRWAYRESISTANCE(Raw):
Determinedbythecalibreofairways
Decreasesaslungvolincreases(hyperboliccurve)
RawhighatRV&lowatTLC
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 FLOWVOLUMELOOPS

SpirogramGraphicanalysisofflowatvariouslungvolumes
TracingobtainedwhenamaximalforcedexpirationfromTLC
toRVisfollowedbymaximalforcedinspirationbacktoTLC
Measuresforcedinspiratory andexpiratoryflowrate
Augmentsspirometryresults
Principaladvantageofflowvolumeloopsvs.typicalstandard
spirometric descriptions identifiestheprobableobstructive
flowanatomicallocation.
 FLOWVOLUMELOOPS
First1/3rd ofexpiratoryflowiseffort
dependentandthefinal2/3rd near
theRViseffortindependent
Inspiratorycurveisentirelyeffort
dependent
Ratioof
maximalexpiratoryflow(MEF)
/maximalinspiratoryflow(MIF)
midVCratioandisnormally1
 FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION
flowvolumeloopsprovide
informationonupperairway
obstruction:
Fixedobstruction:constant
airflowlimitationon
inspirationandexpiration
suchas
1. Benignstricture
2.Goiter
3.Endotrachealneoplasms
4.Bronchialstenosis
 FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION

Variableintrathoracicobstruction:
flatteningofexpiratorylimb.
1.Tracheomalacia
2.Polychondritis
3.Tumorsoftracheaormain
bronchus

Duringforcedexpiration highpleural
pressure increasedintrathoracicpressure
decreasesairwaydiameter.Theflowvolume
loopshowsagreaterreductioninthe
expiratoryphase
Duringinspiration lowerpleuralpressure
aroundairwaytendstodecreaseobstruction
 FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION
Variableextrathoracicobstruction:
1.Bilateralandunilateralvocalcord
paralysis
2.Vocalcordconstriction
3.Chronicneuromusculardisorders
4.Airwayburns
5.OSA
Forcedinspiration negativetransmural
pressureinsideairwaytendstocollapseit
Expiration positivepressureinairway
decreasesobstruction
inspiratoryflowisreducedtoagreaterextent
thanexpiratoryflow
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 ObstructivePattern Evaluation

Commonobstructivelungdiseases
Asthma
COPD(chronicbronchitis,emphysema)
Cysticfibrosis.
 ASTHMA

Peakexpiratoryflowreducedso
maximumheightoftheloopis
reduced
Airflowreducesrapidlywiththe
reductioninthelungvolumes
becausetheairwaysnarrowand
theloopbecomeconcave
Concavitymaybetheindicatorof
airflowobstructionandmay
presentbeforethechangeinFEV1
orFEV1/FVC
 EMPHYSEMA

Airwaysmaycollapseduring
forcedexpirationbecauseof
destructionofthesupportinglung
tissuecausingveryreducedflowat
lowlungvolumeanda
characteristic(dogleg)appearance
totheflowvolumecurve
 REVERSIBILITY

ImprovementinFEV1by1215%or
200mlinrepeatingspirometryafter
treatmentwithSulbutamol2.5mgor
ipratropiumbromidebynebuliser
after1530minutes
Reversibilityisacharacterestic
featureofB.Asthma
Inchronicasthmatheremaybeonly
partialreversibilityoftheairflow
obstruction
WhileinCOPDtheairflowis
irreversiblealthoughsomecases
showedsignificantimprovement
 RESTRICTIVEPATTERN

Characterizedbyreducedlung
volumes/decreasedlung
compliance
Examples:
InterstitialFibrosis
Scoliosis
Obesity
LungResection
Neuromusculardiseases
CysticFibrosis
 RESTRICTIVEPATTERNflowvolumeloop
lowtotallungcapacity
lowfunctionalresidualcapacity
lowresidualvolume.
Forcedvitalcapacity(FVC)maybe
low;however,FEV1/FVCisoften
normalorgreaterthannormaldue
totheincreasedelasticrecoil
pressureofthelung.
Peakexpiratoryflowmaybe
preservedorevenhigherthan
predictedleadstotall,narrowand
steepflowvolumeloopin
expiratoryphase.
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsforgasexchangefunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 TESTSFORGASEXCHANGEFUNCTION

ALVEOLARARTERIALO2TENSIONGRADIENT:
SensitiveindicatorofdetectingregionalV/Qinequality
Nvalueinyoungadultatroomair=8mmHgtoupto25
mmHgin8th decade(d/tdecreaseinPaO2)
AbNhighvaluesatroomairisseeninasymptomaticsmokers
&chr.Bronchitis(min.symptoms)
Aagradient=PAO2 PaO2
*PAO2=alveolarPO2(calculatedfromthealveolargas
equation)
*PaO2=arterialPO2(measuredinarterialgas)
PAO2:
(PB PH2O)*FiO2 (PaCO2/RQ)
 TESTSFORGASEXCHANGEFUNCTION

DIFFUSINGCAPACITY
Rateatwhichgasenterstheblooddividedbyitsdrivingpressure
(gradient alveolarandendcapillarytensions)
Measuresabilityoflungstotransportinhaledgasfromalveolito
pulmonarycapillaries
Normal 2030ml/min/mmHg
Dependson:
thickeness ofalveolarcapillarymembrane
hemoglobinconcentration
cardiacoutput
 TESTSFORGASEXCHANGEFUNCTION

SINGLEBREATHTESTUSINGCO
PtinspiresadilutemixtureofCOandholdthebreathfor10secs.
COtakenupisdeterminedbyinfraredanalysis:
DlCO=COml/min/mmhg
PACO PcCO
DLO2=DLCOx1.23
WhyCO?
A) HighaffinityforHbwhichisapprox.200timesthatofO2,so
doesnotrapidlybuildupinplasma
B) UnderNconditionithaslowbldconc0
C) Therefore,pulmconc.0
 FACTORSEFFECTINGDLCO

DECREASE(<80%predicted) INCREASE(> 120140%

predicted)
Anemia Polycythemia
Carboxyhemoglobin Exercise
Pulmonaryembolism Congestiveheartfailure
Diffusepulmonaryfibrosis
Pulmonary emphysema

Predicted DLCO for Hb= Predicted DLCO * (1.7 Hb/10.22 + Hb)

 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 CARDIOPULMONARYINTERACTION

Stairclimbingand6minutewalktest
Thisisasimpletestthatiseasytoperformwithminimal
equipment.Interpretatedasinthefollowingtable:
Performance VO2 Interpretation
max(ml/kg/min)
>5flightofstairs >20 Low mortalityafter
pneumonectomy,FEV1>2l
>3flightofstairs Lowmortalityafterlobectomy,
FEV1>1.7l
<2flightofstairs Correlateswithhigh mortality
<1flightofstairs <10
6minwalktest<600m <15
 CARDIOPULMONARYINTERACTION

Shuttlewalk
Thepatientwalksbetweencones10metersapartwith
increasingpace.
Thesubjectwalksuntiltheycannotmakeitfromconeto
conebetweenthebeeps.
Lessthan250mordecreaseSaO2>4%signifieshighrisk.
Ashuttlewalkof350mcorrelateswithaVO2maxof11ml.kg
1.min1
 CardiopulmonaryExerciseTesting

Noninvasivetechnique
Effortindependent
Totestabilityofsubjectsphysiologicalresponseto
copewithmetabolicdemands
 BasicPhysiologicalPrinciples

Exercisingmusclegetsenergyfrom3sources storedenergy
(creatine phosphate),aerobicmetabolismofglucose,
anaerobicmetabolismofglucose
Inexercisingmusclewhenoxygendemandexceedssupply
lactatestartsaccumulating lactateanaerobicthreshold(
LAT)
Withincrementalincreaseinexercise expiredminute
volume,oxygenconsumptionperminute,CO2production
perminuteincreases
 WhatToMeasure

Anaerobicthreshold(>11ml/kg/min)
MaximumoxygenutilizationVO2(>20ml/kg/min)
Ventilatory equivalentofO2(<35L)
Ventilatory equivalentofCO2(<42L)
Oxygenpulse(46ml/heartbeat)
 INDEX

1. Bedsidepulmonaryfunctiontests
2. Staticlungvolumesandcapacities
3. MeasurementofFRC,RV
4. Dynamiclungvolumes/forcedspirometry
5. Flowvolumeloopsanddetectionofairwayobstruction
6. Flowvolumeloopandlungdiseases
7. Testsofgasfunction
8. Testsforcardiopulmonaryreserve
9. Preoperativeassessmentofthoracotomypatients
 Assessmentoflungfunctionin
thoracotomypts

Asananesthesiologistourgoalisto:
1)toidentifyptsatriskofincreasedpostopmorbidity&
mortality
2)toidentifyptswhoneedshorttermorlongtermpostop
ventilatorysupport.
Lungresectionmaybef/by inadequategasexchange,pulm
HTN&incapacitatingdyspnoea.
 Assessmentoflungfunctionin
thoracotomypts
Calculating the predicted postoperative
FEV1 (ppoFEV1) and TLCO (ppoTLCO):
There are 5 lung lobes containing
19 segments in total with the division of each
lobe.
Ppo FEV1=preoperative FEV1 * no. of segments
left after resection
19
Can be assessed by ventilation perfusion scan. For eg:
A 57-year-old man is booked for lung
resection. His CT chest show a large RUL
mass confirmed as carcinoma:
ppoFEV1= 50*16/19=42%
 Assessmentoflungfunctionin
thoracotomypts
ppoFEV1(% predicted) Interpretation
>40 Noorminorrespiratory complications
anticipated
<40 Likelytorequire postoperative
ventilation/increasedriskof
death/complication
<30 Nonsurgerymanagementshouldbe
considered

ppoDLCO(% predicted) Interpretation

>40,ppoFEV1> 40%,SaO2>90%onair
<40
<40 andppoFEV1<40%
Intermediate risk,nofurtherinvestigation
needed
Increasedrespiratoryandcardiacmorbidity
Highrisk requirecardiopulmonaryexercise
test
Inadditiontohistory,examination,chestX ray,PFTspre op
evaluationincludes:
ventilationperfusionscintigraphy/CTscan

splitlungfunctiontests
methodshavebeendescribedtotryandsimulatethe
postoperativerespiratorysituationbyunilateralexclusionofa
lungorlobewithanendobronchialtube/blockerorby
pulmonaryarteryballoonocclusionofalungorlobeartery
 Combinationtests

ThereisnosinglemeasurethatisaGoldstandard
inpredictingpostopcomplications

Threeleggedstool

Cardiopulmonary
Respiratory Lungparenchymal
reserve
mechanics function
Vo2max(>15ml/kg/min)
DLco(ppo>80%)
Stairclimb>2flights,6
FEV1(ppo>40%) PaO2>60
minwalk,
MVV,RV/TLC,FVC Paco2<45
ExerciseSpo2<4%
 Pulmonaryfunctioncriteriasuggestingincreasedriskofpost
operativepulmonarycomplicationsforvarioussurgeries

Parameters Abdominal Thoracic

FVC <70%predicted <2lit.or<70%predicted

FEV1 <70%predicted <2lit. pneumonectomy

<1lit. lobectomy
<0.6lit. wedgeorsegmentectomy

FEV1/FVC <65% predicted <50%predicted

FEF2575% <50%predicted <1.6lit. pneumonectomy

<0.6lit. lobectomy/segmentectomy

MVV/MBC <50%predicted <50%predicted

PaCO2 >45mm Hg >45mm Hg

 Look at flow-vol loop and any
airway obstruction pattern

FEV1 /VC >LLN

Yes No
VC>LLN VC>LLN

No No
Yes TLC>LLN TLC>LLN
Yes Yes
No Yes No

Normal Restriction Obstruction mixeddefects

DLCO>LLN DLCO>LLN DLCO>LLN

Yes No Yes No
Pulmonary Yes
No Asthma,bronchitis Emphysema
Normal VascularDs
Neuromuscular
diseases&chest ILD&pneumonitis
wallds
Yes,PFTsarereallywonderfulbutTheydonot
actalone.

Theyactonlytosupportorexcludea
diagnosis.
Acombinationofathoroughhistoryand
physicalexam,aswellassupporting
laboratorydataandimagingishelpfulin
developingaanaestheticplanforptwith
pulmonarydysfunction.