International Journal of Diabetes Mellitus 2 (2010) 47–50

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International Journal of Diabetes Mellitus

journal homepage: ees.elsevier.com/locate/ijdm

Review

Significance of spirometry in diabetic patients

Sultan Ayoub Meo *
Department of Physiology, College of Medicine, King Khalid University Hospital, King Saud University Riyadh, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Spirometry is a widely used pulmonary function test (PFT), ideally suited to describing the effects of
Received 7 November 2009 obstruction or restriction on lung function. It is a powerful diagnostic tool that plays a significant role
Accepted 6 December 2009 in the early diagnosis of lung damage and its associated structures. It is also used to monitor the thera-
peutic efficacy of various treatment regimes and the course of the disease. The spirometric parameters
have gained more popularity when it has been reported that impaired Forced Vital Capacity (FVC) and
Keywords: Forced Expiratory Volume in 1 s (FEV1) are emerging novel risk factors for type 2 diabetes mellitus. These
Diabetes mellitus
spirometric parameter derangements have been evident on spirometry long before the clinical diagnosis
Lungs
Spirometry
of diabetes mellitus or insulin resistance. In spite of this, spirometry is not used routinely as part of a
Pulmonary function test management system in diabetic patients. Its role is neither fully explored, nor fully utilized to achieve
quality of life when managing diabetes mellitus. The aim of the present review is to highlight the evi-
dence based significance of spirometry in the light of peer reviewed published literature. It may serve
as a brief reference for diabetes management teams to enable spirometry to be included in the algorithm
of the routine assessment of diabetic patients.
Ó 2009 International Journal of Diabetes Mellitus. Published by Elsevier Ltd.
Open access under CC BY-NC-ND license.

1. Diabetes mellitus these changes cause pulmonary dysfunction [7,8]. Diabetes melli-
tus can cause pulmonary complications due to collagen and elastin
Diabetes mellitus is a major, rapidly growing public health care changes, as well as micro-angiopathy [9]. Furthermore, pulmonary
problem. It is increasing in incidence, and brings with it long term function impairment and lung dysfunction in diabetic patients is
complications [1]. Chronic hyperglycemia of diabetes mellitus is secondary, due to immune function impairment [10].
associated with continuing damage, dysfunction, and failure of var-
ious organs, especially the eyes, kidneys, nerves, heart, lungs and
2. Spirometry and diabetes mellitus
blood vessels. Diabetes mellitus is an incurable life-long disease,
involving multiple systems, and with devastating complications
Cardio-respiratory clinical features in diabetic patients, such as
which end up in severe disability and death [2]. Diabetes mellitus
shortness of breath, dysponea, wheezing and easy fatigability make
is associated with the ongoing malfunction of various organs and
physicians more alert to coronary artery disease (CAD). No one can
its complications are mainly a consequence of macro-vascular
deny that diabetes mellitus is a major risk factor of coronary artery
and micro-vascular damage [3]. The mechanism by which im-
disease, but it must be borne in mind that the lung is also a target
paired glycemic control may lead to a reduction in lung function
organ in diabetic patients, and such clinical features might be due
is uncertain, though it has been suggested that the increased sys-
to pulmonary complications than CAD alone. A substantial number
temic inflammation associated with diabetes [3] may result in pul-
of patients who present with dysponea shows normal coronary
monary inflammation [4] as well, and hence, it can cause air way
arteries, and even normal cardiac perfusion and systolic function.
damage [5]. Moreover, secondary reduction in the antioxidant de-
Within this clinical scenario, patients’ complaints of shortness of
fense of lung and increased susceptibility to environmental oxida-
breath, dysponea and easy fatigability might need further investi-
tive insults results in the subsequent loss of lung function [6] and
gation. In this situation, the application of spirometry must be fully
ultimately, lung damage. It has been demonstrated that pulmonary
utilized to rule out pulmonary problems. The basic concepts of nor-
complications in diabetes mellitus are due to a thickening of the
mal pulmonary physiology that are involved in spirometry/pul-
walls of alveoli, alveolar capillaries and pulmonary arterioles, and
monary function testing include mechanics (airflows and lung
volumes), ventilation–perfusion interrelationship, diffusion and
gas exchange, as well as respiratory muscle strength [11] (see
* Address: Department of Physiology [29], College of Medicine, King, Khalid
University Hospital, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi
Table 1).
Arabia. Tel.: +966 1 4671604; fax: +966 1 4672567. Spirometry is a powerful tool that can be used to detect, differ-
E-mail address: sultanmeo@hotmail.com entiate, follow and manage patients with pulmonary disorders.

1877-5934 Ó 2009 International Journal of Diabetes Mellitus. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
doi:10.1016/j.ijdm.2009.12.003
48 S.A. Meo / International Journal of Diabetes Mellitus 2 (2010) 47–50
Table 1
Indications of spirometry in diabetic patients.
Diagnostic indications
 Mandatory monitoring of lung functions in diabetic individuals every
two years
 Diabetic patients with history of cigarette smoking, tobacco chewing,
cough, phlegm production, chest pain, dyspnea or wheezing
 Diabetic patients with abnormal laboratory tests such as blood gases
and chest radiograph
 Evaluate the effect of diabetes mellitus on pulmonary function
 Screen all diabetic patients during their initial visits to ascertain the sta-
tus of lungs
 Screen all the diabetic patients with abnormal HBA1C and fasting blood
glucose
 Assessment of pre-operative risk in those diabetic who need to under-
take any surgical process
 When decision is needed for the diabetic patient who underwent an
amputation
Monitoring indications
 Assess the therapeutic intervention related to respiratory illness in dia-
betic patients
 Describe the course of diseases that affect lung function and associated
structures
 Monitor diabetic patients who are exposed to occupational/industrial
hazardous agents
Disability/impairment evaluations
 Assess diabetic patients as a part of a rehabilitation program
 Assess diabetic patients as part of an insurance evaluation
 Assess diabetic patients for social security and legal reasons
Advances in science and technology have made spirometry a much
more reliable, valid and relatively simple tool to incorporate into
routine clinical visits. Spirometry is a basic, widely used pulmonary
function test (PFT). It typically assesses the lung volumes and
flows, and is ideally suited to describing the effects of obstruction
or restriction on lung function [12]. It is now regarded as an inte-
gral component of any respiratory medical surveillance program.
PFT has assumed a key role in epidemiological studies investigat-
ing the incidence, natural history and causality of lung disease
[13]. Although there is no substitute for spirometry, and even in
countries where it is not widely available as a standardized clinical
algorithm or diagnostic pathway, yet, it can greatly assist in the
diagnosis of common airway diseases. Spirometry is essential for
diagnosing respiratory illnesses, assessing their severity, determin-
ing response to treatment and tracking patients’ progress over time
[14]. The utility of spirometry was further recognized when its
applications were highlighted in diabetic patients [15] inhaled
insulin was introduced for the treatment of diabetes mellitus and
researchers discussed its applications in association with inhaled
insulin at various scientific gatherings [16] (see Tables 2 and 3).
3. Diabetes mellitus and lung function
Diabetic mellitus targets lungs and its associated structures, as
it does other organs. Electron microscopic study has shown that in
Table 2
Contraindications of Spirometry in diabetic patients.
 Nausea, vomiting, headache, dizziness (these disorders affect the test
performance)
 Hemoptysis of unknown origin
 Current history of any abdominal or thoracic surgery
 Current history of any limb amputation
 Current history of glaucoma or any eye surgery
 Recent history of severe chest pain, unstable angina or myocardial
infarction
 Thoracic aneurysms/pneumothorax
 Diabetic patients with a history of HIV/hepatitis B/hepatitis C (because
of high risk of transmission of infection. However, spirometry can be
performed after taking high standard sterilizing measures)
Table 3
Patho-physiological factors affecting the lung functions.
Physiological factors:
 Age, gender, height, weight, BMI, ethnicity, pregnancy, posture, exercise
 Customary activity, time of day, season, climate and geographical
location
 Diet (malnutrition)
Environmental factors:
 Air pollution (occupational/environmental exposure)
 Smoking
Pathological conditions:
 Chronic obstructive pulmonary disease (COPD), interstitial lung disease
 Coronary artery disease
 Diabetes mellitus/impaired glucose tolerance/hormonal disorders
 Neuromuscular disorders (Guillain barre syndrome, Myasthenia gravis)
etc.
diabetic patients, all parts of the lung are equally affected, and the
thickening of the basal lamina is of the same order of magnitude in
both the lung and the kidney [10]. Pulmonary damage at an early
stage in most patients with diabetes mellitus is subclinical, and
rarely present with complaints [17]. Spirometry noninvasively
quantifies the physiological reserves in a large micro-vascular
bed that is not clinically affected by diabetes. Lung function may
provide useful measures of the progression of systemic micro-
angiopathy in diabetic patients [17].
In normal healthy non smokers after the age of 35, the expected
decline in lung function (FEV1) is 25–30 ml/year. However, the
average rate of decline of lung function in diabetic patients, as
measured by Forced Expiratory Volume in 1 s (FEV1), is 71 ml/year.
[18] McKeever et al. [19] have observed that an increase in mean
HbA1c is associated with a decrease in the lung function parame-
ters FVC and FEV1. They hypothesize that impaired glucose auto-
regulation is associated with impaired lung function. Asanuma et
al. [20], Lange et al. [21] and Boulbou et al. [22], have reported that
FVC and FEV1 are reduced in diabetic subjects, as compared to the
control subjects. Similarly, Cazzato et al. [23], conducted a cross-
sectional study to assess pulmonary function in children with insu-
lin-dependent diabetes mellitus (IDDM), and reported that FVC and
FEV1 were significantly lower in diabetics than in controls. Simi-
larly, Makkar et al. [24], performed spirometry on patients with
IDDM, and reported that the IDDM patients had reduced FVC,
FEV1 and MEF 25–75%, as compared to their matched control.
Moreover, Rosenecker et al. [25] demonstrated that in patients
with diabetes, FVC and FEV1 declined significantly over the five
year study period, whereas patients without diabetes did not show
a significant decline during this period. Davis et al. [26] have re-
ported that the Forced Vital Capacity (FVC), Forced Expiratory Vol-
ume in 1 s (FEV1), Vital Capacity (VC) and Peak Expiratory Flow
(PEF) were reduced in diabetic patients. Similarly, Meo et al.
[15,27] reported that lung function parameters Forced Vital Capac-
ity (FVC) and Forced Expiratory Volume in 1 s (FEV1), and Peak
Expiratory Flow (PEF) in type 1 and type 2 diabetic patients were
impaired, as compared to their matched controls. Stratification of
results by years of disease showed a duration of disease-response
effect on lung function.
4. Impaired lung function can cause diabetes mellitus
Diabetes mellitus and lung function have a two way cause effect
relationship. It is pertinent to assess respiratory dysfunction
caused by diabetes mellitus, and it is even more pertinent, in
non-diabetic subjects, to assess the risk of diabetes mellitus. The
impaired lung function may be forecast quite reliably many years
before the actual diagnosis of diabetes mellitus. Subjects with re-
duced lung function are at a higher risk of developing insulin
 S.A. Meo / International Journal of Diabetes Mellitus 2 (2010) 47–50
resistance and hyperinsulinemia. Impaired pulmonary function
may increase the risk of developing diabetes mellitus. Subjects
who are predisposed to developing diabetes have decreased spiro-
metric indices many years prior to the diagnosis, compared with
those who do not develop diabetes. This decrement in spirometric
parameters remains after the development of diabetes; however,
the mechanism involved is most probably that of insulin resistance
[28–31].
5. Impaired lung function is emerging risk factor for type 2
diabetes mellitus
Impaired lung function, especially FVC and FEV1, has attracted
mounting attention as a potentially novel risk factor for glucose
intolerance [32], insulin resistance 33 and type 2 diabetes mellitus
[28–31]. The most probable mechanisms include effects of hypox-
emia on glucose and insulin regulation [33], lung-related inflam-
matory mediators and their effects on insulin signaling [32]. Yeh
et al. [34] analyzed longitudinal data of a large sample of middle-
aged adults from a community-based study, and tested the
hypothesis that decreased lung function (FVC and FEV1) is cross-
sectionally associated with features of insulin resistance, and is
an independent predictor of the incidence of type 2 diabetes mel-
litus. Moreover, they also reported that adults with impaired FVC
(% predicted) had various features of insulin resistance, including
higher levels of blood glucose, insulin, triglycerides, lower HDL
cholesterol and higher systolic blood pressure.
Lazarus et al. [33] found that the decrease in FVC, FEV1 and
maximal midexpiratory flow rate at the baseline forecast hyperin-
sulinemia and estimated insulin resistance over 20 years of follow-
up, independent of age, adiposity and cigarette smoking. Similarly,
Eriksson and Lindgarde [35] found that non-diabetic middle-aged
subjects with a 10% decrease in mean vital capacity developed dia-
betes mellitus during a 6-year follow-up. Engstrom and Janzon
[28] demonstrated that decreased FVC and FEV1 predicted the
presence of diabetes. Ford and Mannino [30] reported that FVC
and FEV1 were significantly and inversely associated with the
prevalence of diabetes. They also found that restrictive lung dis-
ease was significantly associated with the incidence of diabetes;
however, this association was not observed in subjects with
obstructive lung disease.
The most credible explanation for the link between low FVC and
FEV1 and diabetes risk is related to hypoxemia-induced insulin
resistance. The animal model studies also reported that experi-
mental hypoxia produces insulin resistance and hyperinsulinemia
in animals [36]. Moreover, exposure to high altitude hypoxia [32]
or hypobaric hypoxia can reduce insulin sensitivity and lead to a
predisposition for the development of type 2 diabetes. Impaired vi-
tal capacity and the risk of diabetes are partially determined by ad-
verse fetal or early-life conditions, and inflammatory precursors
may also favor resistance to insulin action [37]. The main sugges-
tion of the study by Yeh et al. is that impaired lung function (FVC
and FEV1) deserves high attention as an emerging novel risk factor
for type 2 diabetes mellitus. FVC might still be a useful risk predic-
tor, and the FVC-diabetes link could suggest explanations for other
phenomena such as an increased risk of coronary artery disease,
along with impaired lung function.
6. Diabetes mellitus and alveolar gas exchange
Diabetic patients showed impaired alveolar gas exchange
capacity and reduced pulmonary elastic recoil, as compared with
healthy controls [38]. It has also been found that the impairment
of the pulmonary diffusion capacity for carbon monoxide was com-
mon in type 2 diabetes mellitus in Asian Indian patients [39]. The
49
normal physiological reserves that allow alveolar oxygen uptake to
increase in accordance with metabolic demand and exertional
dyspnea may not develop until 40–50% of alveolar gas exchange
capacity is lost. Diabetic lung involvement is best characterized
as a loss of physiological reserves, and it become a cause of exer-
tional dyspnea in diabetic patients [9].
7. Diabetes mellitus and respiratory muscles strength
Respiratory muscle endurance is of interest in pulmonary criti-
cal care and many other areas of medicine. Reduced muscle
strength has been reported in diabetic patients. Bilateral or unilat-
eral diaphragmatic paralysis has been observed in diabetic patients
[40]. In addition [41] conducted a study, and determined respira-
tory muscles endurance by means of a direct MVV test during
the inspiratory and expiratory phases of respiration, by using a
MP-100 student Bio Pac system. They reported that the respiratory
muscles endurance was impaired, and a greater perception of
respiratory exertion was noticed in diabetic patients relative to
their matched controls. Moreover, breathlessness on exertion and
orthopnea in association with type 2 diabetes mellitus has been
also reported. Investigation showed that bilateral diaphragmatic
paralysis due to phrenic neuropathy may be an important, if rare
complication of diabetes, and diaphragmatic function should be
considered in any patient with unexplained breathlessness and
orthopnoea [40].
8. Diabetes mellitus and pulmonary infection
The frequency and enhanced severity of pulmonary tract infec-
tions in uncontrolled diabetes have been well known for a long
time. The availability of antibiotics has made a significant differ-
ence, but infection is probably a more serious threat to life in a dia-
betic than in a non-diabetic individual. Diabetes mellitus is
recognized as an independent risk factor for developing lower
respiratory tract infections [42,43]. The mechanism for increased
susceptibility to infection is due to an alteration in the chemotac-
tic, phagocytic and bactericidal activity of polymorphonuclear leu-
kocytes [44]. The impaired phagocytic function is also one of the
major causes of pulmonary infection in diabetic patients.
9. Diabetes mellitus and pulmonary tuberculosis
The association between diabetes mellitus and tuberculosis (TB)
has been discussed in the literature for a long time. Pulmonary
tuberculosis and diabetes mellitus frequently coexist [45]. It has
been also reported that there is a high prevalence of TB disease
in diabetic children and adolescents [46]. The frequency of tuber-
culosis was 4–5 times more than in non-diabetics. The disease
was more aggressive in poorly controlled diabetics, and is signifi-
cantly associated with the development of pleural effusion [47]. In-
creased reactivation of tuberculosis lesions has also been recorded
in diabetics. It has also been reported that the development of
tuberculosis occurred more frequently in juvenile diabetes and
the occurrence of tuberculosis increased with the duration of dia-
betes, causing a significantly greater mortality rate. In various
infectious conditions of the lung, along with other related investi-
gations, spirometry may also provide reliable information about
the health of the lung.
10. Conclusion
Spirometry is a simple, reliable, valid and powerful tool that can
be used to assess, differentiate, follow-up and manage patients
with pulmonary disorders. Diabetes mellitus is a major public
50 S.A. Meo / International Journal of Diabetes Mellitus 2 (2010) 47–50
health care problem with increasing incidence and long term com-
plications and is a leading cause of illness and death across the
world. Diabetes mellitus is associated with continuing damage,
dysfunction and failure of various organs, including the lungs.
Therefore, when the question of the management of diabetes mel-
litus arises, physicians should be aware of the size of the problem
of pulmonary complications, and must consider the lung as being
as serious as other complications of diabetes mellitus. The im-
paired lung functions (FVC and FEV1) reflects a causative role
played by the lungs in developing diabetes, then optimizing the
health of the lung through cessation of smoking habits, avoidance
of irritants and toxic exposure, control of underlying airway
inflammation and the promotion of physical activity seem war-
ranted. Indeed, it seems time to add the spirometer to the tools
available for monitoring diabetes mellitus and its important seque-
lae. Moreover, physicians must fully utilize Spirometry in the man-
agement of diabetes mellitus.
Conflict of interest statement
None declared.
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