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DISTURBANCE OF RESPIRATORY FUNCTION Lung Volumes

VENTILATION
 process whereby the lungs replenish the gas in the alveoli
 influx of oxygen and efflux of carbon dioxide

Measurements of ventilatory function consist of:

1. Quantification of the gas volume contained in the lungs

under certain circumstances
2. Rate at which gas can be expelled from the lungs

 Tidal Volume (TV): 500ml, normal quiet breathing

 Inspiratory Reserve Volume (IRV): volume of air that can
still be inhaled after a normal inspiration
 Expiratory Reserve Volume (ERV): maximal expiration
after a normal tidal breathing

 Forced Vital Capacity- maneuver where we inhale

Spirometer  measures the volume of air that goes in and out of maximally and exhale maximally
the lungs. The patient inhales a known volume of helium and
oxygen.
FVC – can be measured by plotting its volume against the time
Techniques to measure lung volumes

1. Helium dilution method- subject repeatedly breathes 1

in and out from a reservoir w/ known volume of gas FVC 2

containing trace amount of helium and oxygen. 3

4 Volume
o Helium is diluted by the gas previously present in the 5
(Liters)

lungs and very little is absorbed into the pulmonary 6

circulation.
7
o Knowing reservoir volume & initial & final helium
concentration, the volume of gas present in the lungs 8

can be calculated by the formula:

o C1V1 =C2V2 where: 1 2 3 4 5 6 7
o V2 – total gas volume (FRC + vol of spirometer)
Time (Seconds)
o V1- vol of gas in the spirometer
o C1- initial concentration of He FEV1 is the fraction of the expired volume in 1 second. Here, in 1
o C2- final He concentration second, FEV1 is approximately 4.5L.

** The helium dilution method may underestimate the volume of

gas in the lungs if there are bullae in the lungs because helium will 1

not enter the bullae therefore it will not be computed. Body FVC 2
plethysmograph is more appropriate. 3

4 Volume
2. Body plethysmograph- patient sits in a sealed box while (Liters)
5
panting against closed mouthpiece
6

o because there is no airflow into or out of the 7

plethysmograph, the pressure changes in the thorax 8

during panting cause compression and rarefaction of

gas in the lungs & simultaneous rarefaction &
1 2 3 4 5 6 7
compression of gas in he plethysmograph
o by measuring the pressure changes in the Time (Seconds)

plethysmograph and at the mouthpiece, the volume of

gas in the thorax can be calculated using Boyle’s law Flow of Air
o P1V1=P2V2 - Measured when FEV1 is divided by FVC.
o P1, V1 are known volumes; P2 – alveolar pressure
o V2- represented by the volume in the mouth piece.
o Best in patients with emphysema and other COPD

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2 ways to graphically represent the lung volumes It is important to memorize the normal configuration of a flow
volume loop as you are going to see later, it plays a pivotal role
in the interpretation of the spirometry.

VOLUME
TLC
Abnormal Ventilatory loops

LOOP
TIME
ABNORMAL NORMAL
RV

FLOW
RESTRICTIVE OBSTRUCTIVE
(Volume)

TIME
VOLUME

Flow rate
1. Volume against time Volume
2. Flow against volume

Let us first discuss the genesis of flow volume loop RESTRICTIVE RESTRICTIVE
(PARENCHYMAL) (EXTRA PARENCHYMAL)

1. Restrictive
Expiration - Hallmark: Decrease in lung volume (X-axis)
- Flow rate is normal
FLOW (LPS)

2 subtypes
VOLUME (L)
o Restrictive Parenchymal
- Tall but thin ventilator loop
- Example: pulmonary fibrosis
Inspiration
- Limitation on lung volume due to the parenchyma
- Can be interstitial or alveolar problem

Graph in the Flow Volume Loop
On the X-axis, is the volume of the lungs, while on the Y-axis is the
flow of air. The expiratory events are recorded on the upper half
of the graph, and all the inspiratory events are recorded on the
lower half.
o Restrictive Extraparenchymal
- Example: abnormalities in the pleura (pleural effusion),
neuromuscular diseases (Guillain-Barre, Myasthenia
Gravis) , chest wall disorder (kyphosis).
- Massive pleural effusion limits lung expansion
- Flow volume loop is narrow and short  contracted
volume and flow rate

ABNORMAL LOOP RESTRICTIVE

8
6 OBSTRUCTIVE
(Flow rate)
4
2 LOWER UPPER
FLOW (LPS)

VOLUME (L)

2 4 6 VARIABLE FIXED
Flow rate

2
4
6 Exp

8
Volume
FVC Insp
TLC RV
INTRA EXTRA
At the start of inspiration (look at lower half), air flow is zero and THORACIC THORACIC
as we inhale, airflow peaks at mid-inspiration. At the end of
maximal inspiration, we reach the total lung capacity. 2. Obstructive
- Hallmark: decrease in the flow rate (Y-axis)
When we ask the patient to exhale maximally (look at upper half), - Lung volume is normal
there is a sudden surge of the flow and there will be a rapid peak
in airflow then a gradual drop in airflow as we reach the residual Lower Airway obstruction
volume. - distal to the L. main bronchus
- Scooped out pattern of the expiratory rim is
pathognomonic

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Upper airway obstruction generated during the test. Thus during the test, the patient
- proximal to L. Main bronchus was able to generate 4.5 L of FVC.
• The fourth column is the % predicted. It just the computed
Classified into two types: value of the actual over the predicted multiplied by 100. It
1. Variable just tells you that the actual numbers produced by the
o Intrathoracic – ex. Mass on the upper airway, patient is just 90% of the predicted.
limits expansion, normal inspiration but
difficult to exhale When do we classify the parameter as normal?
o Expiration is contracted • There are several ways; however the most simple is the
o Extrathoracic – inspiration is contracted percentage system.
o (+) stridor – predominantly inspiratory
• In this system you just to memorize the numbers 80 and 70.
2. Fixed – ex. Tracheal stenosis • With regards the FEV1 and FVC, if the % predicted is 80%
o box like flow volume loop and above, it is considered as normal.
o contracted inspiration and expiration • With regards the FEV1/FVC, if the actual value is 70% and
o (+) stridor above, it is considered as normal. If ratio is below 70%, it is
automatically obstructive lung disease.
Identify whether restrictive or obstructive, and its specific type:
(will appear on exam) • In this report, is the FEV1 normal? Yes, because the %
predicted is 80% and above.
• In this report, is the FVC normal? Yes, because the %
predicted is 80% and above.
• In this report, is the FEV1 over FVC normal? Yes, because the
actual value is above 70.

Algorithm to interpret Spirometer results

Components of a Spirometry Report

Remember: Spirometry result is not a confirmatory test whether

there is restrictive or obstructive lung disease. It is used for
ruling out whether a certain condition is a combined condition or
pure obstruction, pure restrictive or normal spirometry results.
To confirm spirometry results, one must check the Total Lung
Capacity.
2 Parts of the Report

1. Demographic data Common Respiratory Diseases by Diagnostic Categories

2. Parameters measured Obstructive Restrictive - Restrictive- Extra
Parenchymal Parenchymal
In the measured parameters portion of the spirometry results, Asthma Sarcoidosis Neuromuscular Chest wall
there are usually at least 4 columns. Chronic Idiopathic Diaphragmatic Kyphoscolosi
Bronchitis pulmonary paralysis s
• The first column -measured parameters. Emphysema fibrosis Myasthenia Obesity
• The second column - predicted values. It is the predicted Bronchiectasis Pneumoconios gravis Ankylosing
values that the patient should generate based on his or her Cystic fibrosis is Gullain-Barre spondylitis
demographic data. For example for this patient with this Bronchiolitis Drug or Muscular
demographic data, he is expected to generate a FVC of 5 L, Radiation Dystrophies
FEV1 of 4 L and a ratio of 80. induced Cervical spine
• The third column - actual results from the post interstitial injuries
bronchodilator values. It is the values that the patient lung disease

PULMO – DISTURBANCES OF RESPIRATION (DR. BAYOT) CASTILLO, N.P. WHATTHEF!2017


Bronchiolitis
 Hyperactivity of the airways in the neonates and young
children
Sarcoidosis
 (+) nodules – limit expansion of the lungs
Cystic fibrosis
 (+) fibrosis – also limits expansion of lungs
MEASUREMENT OF GAS EXCHANGE
Arterial Blood Gases
 most commonly used measures of gas exchange: PaO2
and PaCO2
 these partial pressures do not measure directly the
quantity of O2 and CO2 in the blood but the driving
pressure of gas in the blood
 the actual quantity or content of a gas in blood also
depends on the solubility of gas in plasma & ability of
any component of blood to react with or bind the gas of
interest
 since hemoglobin is capable of binding large amouts of
O2, oxygenated Hgb is the primary form in w/c O2 is
transported in blood
 Actual content of O2 in blood depends on the
hemoglobin concentration and on PaO2.
 PaO2 determines what percentage of Hgb is saturated
with O2 based on the position on the oxyHgb
dissociation curve
 PaO2 is the measurement of used to assess the effect of
respiratory disease on the oxygenation of arterial blood.
Alveolar-Arterial O2 gradient or A-a gradient
 a useful calculation in the assessment of oxygenation is
the alveolar-arterial O2 difference (PAO2-PaO2)
PAO2 (alveolar pressure)- PaO2 (arterial pressure)
 It takes into account the fact that alveolar and arterial
PO2 can change depending on the level of alveolar
ventilation reflected by arterial PCO2.
 When a patient hyperventilates and has a low PaCO2,
PAO2 and PaO2 will rise.
 In healthy young person breathing room air, the A-A
gradient is normally less than 15 mmHg; this value
increases with age and may be as high as 30 mm Hg in
elderly patients
Pulse oximetry
 Using a probe clipped over a pts finger, it calculates
oxygen saturation (rather than PaO2) based on
measurement of absorption of 2 wavelengths of light by
Hgb in pulsatile cutaneous blood.
Problems with its use:
1. Because oxyHgb dissociation curve becomes flat above
PaO2 of 60 mmHg (SaO2 of 90%), the oximeter is
relatively insensitive to changes in PaO2 above this
level.
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2. When cutaneous perfusion is decease (low cardiac
output, hypotensive patients or use of vasoconstrictors)
the signal from the oximeter maybe less reliable or even
unobtainable.
3. Other forms of Hgb (carboxyHgb, metHgb) are not
distinguishable from oxyHgb when only 2 wavelengths
of light are used, thus unreliable in the presence of
significant amounts of carboxy and metHgb.
Diffusing Capacity of lung for Carbon monoxide (DLCO)
 assess the ability of gas to diffuse across the alveolar-
capillary membrane
 a small concentration of CO (0.3%) is inhaled, in a single
breath that is held approximately 10 seconds.
 Now, the CO is diluted by the gas present in the alveoli
& is taken up by Hgb as the RBC course thru the
pulmonary capillary system.
 Concentration of CO in exhaled gas is measured & DLCO
is calculated as the quantity of CO absorbed per min per
mmHg pressure gradient from alveoli to the pulmonary
capillaries.
Depends on:
1. Alveolar-capillary surface area available for gas
exchange
2. Thickness of alveolar-capillary membrane
3. Degree of V/Q mismatching
4. Patient’s Hemoglobin level
Decreased DLCO
 Interstitial lung disease- scarring of alveolar
capillary units diminishes the area of the alveolar-
capillary bed and pulmonary blood volume
 Emphysema- alveolar walls are destroyed , surface
area of alveolar-capillary bed is diminished
Pulmonary vascular disease (recurrent pulmonary
emboli, primary pulmonary HPN)- decrease in x-
sectional area & volume of the pulmonary vascular
bed
Elevated DLCO
 Increased pulmonary blood volume (CHF)
 Alveolar hemorrhage (Goodpasture’s syndrome)
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Diagnostic approach to patient with hypoxemia

Mechanisms of Hypoxemia (know examples of each)

o Hypoventilation
o Shunt
o V/Q mismatch
 Most common cause of hypoxemia among the mechanisms
 Either a problem in ventilation or perfusion
o Decreased inspired fraction of inspired O2 (FiO2)

Samplex!

10. Mechanism of hypoxemia in atelectasis

Match the following:
A. V/Q mismatch
A. Low FEV1/FVC, increased RV B. hyperventilation
B. Low TLC, Low VC, Low RV C. shunt
C. Low TLC, Low VC, increased RV D. low inspired O2
D. Increased TLC, increased VC
E. Normal 11. The following is the spirometry report of patient X.
what does his results suggest?
1. Ankylosing Spondylitis FEV1 =85
2. Cystic Fibrosis Total lung capacity- decrease
3. Sarcoidosis FVC= 72
4. Obesity Residual volume - normal
5. Guillian Barre Syndrome FEV1/FVC ratio= 75
6. Kyphoscoliosis DLCO – Normal
7. Bronchiolitis
8. Pneumoconiosis A. Normal spirometry
B. Restrictive ventilatory defect
C. Obstructive respiratory deficiency
9. Not applicable with restrictive ventilation defect D. Obstructive and restrictive respiratory deficiency

A. Myasthenia Gravis
B. Bronchiolitis
C. Obesity
D. Sarcoidosis

PULMO – DISTURBANCES OF RESPIRATION (DR. BAYOT) CASTILLO, N.P. WHATTHEF!2017

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