8 PART I Preoperative

CHAPTER 4
Pulmonary Function Tests
Ruchir Gupta, MD

FIGURE 4-1. Normal spirogram

Total
Tidal Vital lung
volume capacity capacity

Expiratory
reserve
Functional volume
residual
capacity
Residual
volume

Reproduced from Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison’s
Principles of Internal Medicine. 18th ed. Figure 252-2. Available at: www.accessmedicine.com.
Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

FIGURE 4-2. Normal lung volumes

Maximal inspiration

Inspiratory reserve
Inspiratory volume (IRV)
capacity (IC) 2.5 L
3.0 L
Vital
capacity (VC)
Total lung Tidal volume (VT) 4.5 L
capacity (TLC) 0.5 L Resting
6.0 L volume
Expiratory reserve
volume (ERV)
Functional 1.5 L
residual
capacity (FRC)
3.0 L Maximal expiration
Residual volume (RV)
1.5 L
No air in lungs

Reproduced from Levitzky MG. Pulmonary Physiology. 7th ed. Figure 3-1. Available at:
www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
 Pulmonary Function Tests CHAPTER 4 9

Pulmonary Function Tests in Disease States

Respiratory variable
Vital capacity
Total lung capacity
FEV1 /FVC ratio
Mid-maximal expiratory flow
Maximum breathing capacity
DLCO
N, normal; ↓, decreased; ↑, increased.
Obstructive Restrictive (i.e., pulmonary
(i.e., asthma, COPD) fibrosis, pneumonia)
N or ↓ ↓
↑ ↓
↓ N or ↓
↓ N
↓ N
Asthma: N or ↓ ↓↓↓
COPD: ↓↓

FIGURE 4-3. Components of the flow–volume loop

10
Flow (l/sec)

Vital capacity
8

6
Expiratory
reserve
4 volume
Inspiratory
Expiration

capacity First second mark

2

0
0 1 2 3 4 5 6 7
Inspiration

Volume (liters)
–2
Tidal
volume
TLC RV
–4

–6

By convention, expiration is up and inspiration is down.

10 PART I Preoperative

FIGURE 4-4. Alterations of flow–volume loop in disease states

Normal Mild obstructive Severe obstructive

lung disease lung disease

Variable intrathoracic Variable Fixed intra- or

upper airway extrathoracic upper extra-thoracic upper
obstruction airway obstruction airway obstruction

Restriction Restriction Bronchodilator

(pulmonary fibrosis) (kyphoscoliosis) pre- & post-
 Pulmonary Function Tests CHAPTER 4 11

FIGURE 4-5. Preoperative testing algorithm to predict surgical outcome for

pneumonectomy

Initial tests : PFTs

1. FEV1 ≥ 2 liters
2. FEV/FVC ratio ≥ 50% predicted
3. MBC ≥ 50% predicted

Yes No

Split function lung scan

FEV1 ≥ 800 ml

Patient likely to
Yes No
survive

Cardiac catherization

PaO2 < 45
PAP > 35

Yes No

Survival unlikely