Basic approach to

PFT interpretation
Dr. Giulio Dominelli
BSc, MD, FRCPC
Kelowna Respiratory and
Allergy Clinic
Disclosures
 Received honorarium from Astra Zeneca
for education presentations
Tasked
 Asked to talk about the
interpretation of
pulmonary function tests

 PFT interpretation is a
HUGE area and we could
easily spend the entire
lecture on any single
component and the
controversies within
them…
In order to tackle this,
I will assume a
basic understanding
of the test
mechanics,
measurements,
quality control and
lung physiology that
is used to generate
the data….

Adapted from Pulmonary Function Tests in Clinical practice. Figures 2.1

 Focus

Taking the data to the bedside

Outline
The major focus Brief overview
 Before the data  Muscle strength
 Flow volume loops  Methacholine
 Spirometry  CPET
 Lung volumes
 Diffusion  Examples

Not going to cover:

ABG, Overnight oximetry or sleep studies, walk tests
 Disclaimer
 There are many approaches
 Thisis the method I take when
approaching interpretation of
PFTs

 Find systematic away to

approach

 Follow it for each test

Before the data
 Who the test is on
 Ensure the demographics make sense
 Alter your expectations

 Who ordered the test and why

 GPvs. Specialist
 What is their clinical question
Before the test
 Did it meet ATS standards
 Acceptability and Reproducibility
 Will not focus on these criteria
 Special comments
 Patienteffort
 Problems encountered
 Smoking history, other clinical symptoms
 Spirometric curves - qualitative
analysis
 Flow-Volume  Volume-Time

Adapted from Pulmonary Function Tests in Clinical practice. Figures 1.2 and 1.11
Volume-Time curve
 Adequacy of the test (6 seconds)
 Gives insight into pattern of disease
 Obstructive vs. restrictive

http://www.nataliescasebook.com/tag/spirometry
Accessed Sep 205
 Flow-Volume Curve
 Ensure adequate test
 Free from artefact
 Insight into pattern of
disease
 Obstructive or
restrictive
 Screen for upper
airway obstruction

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.11

 Flow-Volume Curve: Obstruction

 Low peak flows

 Expiratory limb is
concave or ‘scooped’

 Total volume is
typically lower

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.18

 Flow-Volume Curve: Restriction
 Shape can vary depending on etiology
 All lower volume and no concave shape

Parenchymal disease Chest Wall NMD

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.19

Flow-Volume Curve: Upper airway
obstruction
 Variable: obstruction comes and goes with
maximal inspiratory or expiratory efforts
 Fixed: never changes with forced efforts
 Unlike lower airway disease, the
obstruction is present throughout the
expiratory cycle
 Ie: not just at low lung volumes
 Flow-Volume Curve: Upper airway
obstruction

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.20

Upper airway obstruction: Causes

 Variable extrathoracic
 Dynamic tumors or strictures, vocal cord
paralysis
 Variable intrathoracic
 Dynamic tumors or strictures and
tracheomalacia
 Fixed
 Non-dynamic tumors and fibrotic strictures
Looks normal by numbers

Clearly not an acceptable test

Spirometry – Quantitative analysis
Controversies
 Will not address
 LLN vs. fixed cut off for obstruction
 Using FVC vs. VC

 The absolute cut off of 0.7 is still the most

commonly used and understood
 From GOLD
 Obstruction
 Grade the severity  Assess for
 This is per GOLD bronchodilator response

 Mild≥ 80%  ≥12%

 Moderate 50-79% and
 Severe 30-49%  ≥200ml
 Very severe <30%
 Can be FVC or FEV1
Reversibility
 A positive bronchodilator response is
supportive of the diagnosis of asthma
 Can also been seen in COPD

 False negative
 Medications/Caffeine not withheld, specific
antigen, exercise induced
FEF 25-75%
 It is not specific for small airway disease
 It is highly variable between people and
between test
 Does not indicate bronchodilator response

 May assist in ‘early’ or ‘borderline’

detection
Examples
Moderate obstruction
without reversibility.
Query cough due to asthma
or COPD?
Mild non-reversible
obstruction.
Consistent with COPD
 Suggestive of a
restrictive disorder

Needs full PFTs

 Lung volumes
 Nitrogen washout,
Inert gas dilution
 **Plethysmography
 By using Boyle’s law
we can derive the lung
volumes and
capacities that we can
not get from
spirometry
 TLC, RV, FRC

Adapted from Pulmonary Function Tests in Clinical practice. Figure 2.3

Lung volumes
 Needed to identify

 Restriction
 Possible etiology
 Hyperinflation
 Gas trapping
 Mixed disorders
Total lung capacity: TLC
Increased Decreased
 COPD  Restrictive ILD
 Acromegaly  Chest wall
 Athletes (swimmers)  NMD
Severity of restriction
Restriction Hyperinflation
 Mild 60-80%  >120%
 Mod. 50-60%  Generally don’t grade
 Severe <50%
Residual Volume
 Increased – air trapping
 Obstructive disorders such as COPD and
asthma

 Decreased
 Parenchymal restriction
RV/TLC ratio
 Restriction
 Parenchymal
 Normal as symmetrical decrease
 Extra-parenchymal
 Increased as typically no change in RV
 Obstruction
I generally do not look at it, but usually
increased
 FRC – insight into lung compliance
 Increased
 Increases slightly with
age
 Emphysema
 Due to loss of elastic
recoil
 Decreased
 Lungfibrosis
 Obese
 Low ERV
 Supine
Bring it together: Disease patterns

 Differentiate obstructive subtypes

 While both asthma and COPD may have gas
trapping and a high RV/TLC
 Asthma should not have hyperinflation
 Confirm restriction suspected on
spirometry
 Can have low VC due to gas trapping
Disease patterns
 Differentiate restrictive subtypes
 Parenchymal restriction
 Low TLC, RV, but normal RV/TLC
 Extra-parenchymal restriction
 Low TLC, but normal RV and high RV/TLC
 Especially NMD where RV may be very high due to
expiratory muscle weakness
 Identify mixed
 Low ratio on spirometry, but low TLC
 RV can be variable
DLCO
 Diffusing capacity of
the lungs for carbon
monoxide measures
the ability of the lungs
to transfer gas from
inhaled air to the red
blood cells in
pulmonary capillaries
Grading severity

 >75% normal
 60-75% mild
 40-60 moderate
 <40% severe
DLCO
 Decreased  Increased
 Need to consider the  Pulmonary
ddx in the context of hemorrhage
the rest of the PFT  Polycythemia
 Obstruction
 Increased pulmonary
 Restriction
blood flow
 Isolated DLCO
 Mueller, exercise,
pregnancy, supine
position, left to right
shunt
Differential diagnosis

Obstruction Isolated Restriction

Emphysema Anemia ILD

Bronchiolitis CO Pneumonitis

Obstructive ILD Pulmonary NMD

LAM/Sarcoid vasculature
Early ILD Chest wall
DLCO adjustment
 Hemoglobin
 Polycythemia or anemia can alter the DLCO
 Non-linear relationship

 CO
 Activesmokers can effect the measurement
and can use ABG to adjust
 Alveolar volume
DLCO adjustment - VA
 Most labs report a DLCO that is corrected for the
measured lung volume (DLCO/VA)
 The concept comes from normal subjects who
inhaled a submaximal volume
 However, routine use of the DLCO/VA is not
recommended
 The correction is not linear and does not give insight
in to the reason for low VA
 Incomplete alveolar expansion, diffuse versus localized loss
of alveolar units, and poor alveolar mixing
 I only use it to consider extraparenchymal
restriction
Examples
 Scooped flow volume
Very long expiratory phase
Severe non-reversible obstruction, gas trapping, mild gas
exchange……..bronchiectasis/ACOS?
Ddx isolated DLCO
Mixed obstructive / restrictive
Severe gas exchange
Likely not just simple COPD
Severe obstruction, hyperinflated, gas trapping, severe
gas exchange
The supplemental tests
 Muscle strength

 Methacholine
Muscle strength
 MIP and MEP
 Useful in monitoring
known NMD
 In those with
restriction or
dyspnea NYD
 Can be seen before
clinical weakness
Muscle strength
 Low MIP, normal MEP
 Diaphragmatic paralysis
 Low MEP, normal MIP
 Spinal cord injury below C5
 Low MIP can also be seen in gas trapping
 Diaphragm at a mechanic disadvantage
 MEP <40 predicts ineffective cough
Muscle strength
 Supine and upright FVC
 Drop in FVC of <10% in normal
 Drop of >30% suggests bilateral
diaphragmatic paralysis
Mild-moderate restriction and borderline gas exchange that
overcorrects for Va
?Extra-parenchymal restriction, specifically NMD
Bronchial Challenge test
 Used to help in diagnosing or excluding asthma
by provoking bronchoconstriction by controlled
external stimuli
 Most commonly methacholine used (M-agonist)
 Test and severity

Adapted from Pulmonary Function Tests in Clinical practice. Figure 4.1

Interpretation
 A negative methacholine test is very useful
in ruling out asthma
 Very high negative predictive value
 False negative: medication and specific Ag
 A positive methacholine does not equal
asthma
 Must be taken in clinical context
False positive methacholine
 Allergic rhinitis without asthma
 Smokers/COPD
 CHF
 Bronchiectasis / CF
 Sarcoid
 Recent URTI
 A quick word on CPET

Adapted from Pulmonary Function Tests in Clinical practice. Figure 9.2

CPET
 An underutilized tool
 Determine exercise capacity
 Exercise prescription, disability
 Identify the cause of exercise impairment
 Dyspnea NYD
 Select therapy and response
 Thoracic surgery and response to PH Rx
 Diagnose exercise induced asthma
Reference material
 Pulmonary function tests in clinical
practice
 DrAltalag, Road and Wilcox
 Springer 2009
 Interpretative strategies for the lung
function tests
 Pellegrinoet al.
 Eu. Respir. J. 2005
Special thanks
 To all the RTs at KGH
 Especially
the PFT department where all my
examples came from
Questions or some more examples
 Certainly looks like asthma
Patient reports previous smoking history
Mild reversible obstruction with gas trapping
Normal diffusion
Consistent with asthma and not COPD
 Not diagnostic of asthma
Certainly severe obstruction, high FRC, borderline diffusion
Asthma, COPD, ACOS
 Not obstructive (post bronchodilator)
Moderate restriction
Severe diffusion, probably PHTN and restriction
Very severe obstruction, hyperinflation, gas trapping and
diffusion
Severe COPD