LUNG FUNCTION TEST

LEARNING OBJECTIVES:
1. Understand the role of spirometry tests as an objective measurements for lung
function in the diagnosis of respiratory, follow-up treatment and for clinical physiology
research
2. Understand indication, contraindication and how to perform the spirometry
3. Perform the static and dynamic spirometry test.
4. Perform interpretation of spirometry

BASIC THEORY
Lung function test (LFT) or pulmonary function test evaluate how well the lungs work.
The tests determine how much air the lungs can hold, how quickly we can move air in and out
of our lungs, and how well our lungs put oxygen into and remove carbon dioxide from blood.
The LFT can detect the presence and degree of pulmonary functional abnormalities. It can
differentiate between obstructive, restrictive and mixed obstructive/restrictive disorder. It
can help the evaluation of the presence and degree of increased airway responsiveness, and
assess the risk of therapeutic or diagnostic interventions. The LFT test monitors the effects of
therapy and contributes to an accurate prognosis of disease and disability. This LFT also use
for epidemiology surveys and clinical and physiological research. The most basic and
frequently performed for LFT is spirometry. However, although it is safe for most people, some
people should avoid this procedure (Altman M A, 2012):
• Excessive tiring (patients who cannot expend the required effort for testing)
• Severe respiratory distress
• Patients not motivated or desiring to take the test
• Children too young
• Recent eye surgery, because of increased pressure inside the eyes during the
procedure
• Recent belly or chest surgery
• Chest pain, recent heart attack, or an unstable heart condition
• A bulging blood vessel (aneurysm) in the chest, belly, or brain
• Active tuberculosis (TB) or respiratory infection, such as a cold or the flu

Spirometry is a physiological test that measures how an individual inhales or exhales

volumes of air as a function of time. The primary signal measured in spirometry may be
volume or flow. The spirometry test is performed using a device called a spirometer which
comes in several different varieties

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 Hutchinson Spirometer Microlab Spirometer Digital Spirometer

. The spirometry test involves two kinds of testing, static that are purely volume-base and
dynamic that based on time. We have been already study the static spirometry at block A.3,
at this block we will study the dynamic spirometry. Since we have to compare static and
dynamic elements of spirometry to gain information about lung function, we also do the static
test. The result of spirometry test can be display in volume-time curve and flow-volume curve.

Figure 2. Example of volume-time curve spirograph

(West JB, 2013; Crapo RO, 1994)

Figure 3. Example of flow-volume curve spirograph

(Crapo RO, 1994)

The most common parameter for static spirometry is vital capacity (VC). The VC is the
largest amount of air that can be expired after a maximal inspiratory effort. The other static
parameters are inspiratory reserve volume (IRV), expiratory reserve volume (ERV) and tidal
volume (TV).
The dynamic spirometry parameters are forced vital capacity (FVC), the amount of air
which is exhale in the fastest way and during deepest expiration after maximum inspiration.

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Forced expiratory volume in 1 second (FEV1), the fraction of the FVC expired during the first
second of a forced expiration. The FEV1 is normally decreased during diseases that increase
airway resistance (like narrowing bronchi such as asthma or chronic obstructive pulmonary
disease). The FEV1 should equal roughly 75% FVC. The FEV25-75% is the slope of the spirogram
between 25 to 75% of FVC manouver. It used to be an indication of small airways disease.
FEV25-75 is refer to as maximal mid expiratory flow (MMEF) in some centers. Prolongation of
expiratory flow rates is increased by bronchospasm (in asthma), impacted secretions (in
bronchitis), and loss of lung elastic recoil (in emphysema). In fixed obstruction of the upper
airway, flow is limited by the caliber of the narrowed segment rather than by dynamic
compression, resulting in equal reduction of inspiratory and expiratory flow rates. In
restrictive lung disorders, increased tissue elastic recoil tends to maintain the caliber of the
larger airways so that at comparable lung volumes, flow rates are often higher than normal.
The other parameter for dynamics spirometry is maximal voluntary ventilation (MVV),
which determined by encouraging the patient to breathe at maximal tidal volume and
respiratory rate for 12 sec, the volume of air expired is expressed in L/min. The MVV generally
parallels with the FEV1 and can be used to test internal consistency and estimate patient
cooperation. The MVV can be estimated from the spirogram by multiplying the FEV1 (L)x40.
When the MVV is disproportionately low in a patient who seems to be cooperating,
neuromuscular weakness should be suspected. Except in advanced neuromuscular disease,
most patients can generate fairly good single-breath efforts (e.g. FVC). Because MVV is much
more demanding, it can reveal the diminished reserves of weak respiratory muscles. The MVV
decreased progressively with increasing weakness of the respiratory muscles and along with
maximum inspiratory and expiratory pressures, may be the only
demonstrable pulmonary function abnormality in patients with moderately severe
neuromuscular disease. The MVV is important preoperatively because it reflects the severity
of airway obstruction as well as the patient's respiratory reserves, muscle strength and
motivation.

Figure 4A. FEF 25-75% Figure 4B. MVV

(West JB, 2013; Crapo RO, 1994)

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TIME ALLOCATION

Time Activity Students Instructor Material

5 minutes Pre test Answering - MCQ
the questions
30 minutes Introduction Listen Explain video, Power
point
60 minutes Practice Practicing Guiding and equipment
discussing
20 minutes Discussion Discussing Discussing and
lesson learned
5 minutes Post test Answering -
the questions

MATERIAL AND EQUIPMENT

1. Harvard Spirometer unit (volume displacement spirometer) and or Pony FX desktop

spirometer unit (flow sensing spirometer)
2. Nose Clips
3. Mouthpiece
4. Alcohol 70%
5. Recording paper

PROCEDURE

Patient preparation
Performing spirometry need patient/probandus preparation, equipment and
procedure/maneuver in order to achieve good quality result. In adition to consider indication
and contraindication, the activities patient should preferably be avoided prior to lung function
testing: smoking within at least 1 h of testing, consuming alcohol within 4 h of testing,
performing vigorous exercise within 30 min of testing, wearing clothing that substantly
restrics full chest and abdominal expantion and eating in large meal within 2 h of testing.
Testing may be performed either in the sitting or standing. The patient’s age, sex, weight, and
ras are recorded for use in the calculation of reference/prediction values.

Maneuver of spirometry
Procedure of spirometry using slow vital capacity maneuver for testing static and
forced vital capacity maneuver for testing dynamic volume and capacity of the lung.

a. Slow vital capacity (SVC) maneuver

1. Clean up the mouthpiece of spirometer with alcohol 70% solution or use
disposable mouthpiece.
2. Set the pointer at the middle of the graph paper.
3. Connect the spirometer to the electrical power source and turn it on (green lamp
is on)
4. Set te paper velocity at the 2,5 mm/second.

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 5. Hold the nose with nose clip.
6. Put the mouthpiece around the mouth tightly, breathing as usual by your mouth
through this mouthpiece (inhale and exhale), subsequently inhale as deeply as
possible and exhale with maximum effort.
7. Repeat by 3-8 times, until we get at least three similar result (difference of each
tidal volume <5%, vital capacity < 150 ml), then we get a spirogram like picture
below
8. Calculate the FVC of the subject (1 mm = 30 ml)
9. Calculate the FVC/FVC prediction using FVC prediction equation (Table 1) and
Pneumobile (Table 2 and 3). FVC is considered normal if > 80% of prediction.

b. Forced vital capacity (FVC) maneuver using Harvard Spirometer unit for measure FVC,
FEV1, FEF25-75
1. Set the recording pen in the middle part of the paper.
2. Set the drum speed at 20 mm/sec
3. Place the subjects in the correct posture
4. Attach nose clip, place mouthpiece and close lips around the mouthpiece
5. Inhale completely and rapidly
6. Exhale maximally until no more air can be expelled while maintaining an upright
posture.
7. Repeat for a minimum of three maneuvers that acceptable
8. Express FVC in L or mL (1 mm= 30 ml)
9. Calculate the ratio of F FEV1 /FVC. The result considered normal if  70%.
10. Calculate the FEV1 prediction using FEV1 prediction equation (Table 1) and
Penumobile (Table 4 and 5).
11. Calculate the FEV1 /FEV1 prediction. It is considered normal if the value is  75%.
12. Measure the mean forced expiratory flow between 25% and 75% of the FVC (FEF25–
75%) or MMEF. This index is taken from the blow with the largest sum of FEV1 and
FVC.

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Spirograph of forced vital capacity manouver. IC: inspiratory capacity. TLC: total lung capacity. FRC: fungsional
residual capacity. FEF25-75%: Forced expiratory flow 25-75%. FEV1: forced expiratory flow in 1 second. FET:
forced expiratory time. FVC: forced vital capacity. RV: residual volume.

13. Calculate the FEF25-75% prediction using equation below (Table .1)
14. Calculate FEF25-75%/FEF25-75% prediction. It is considered as normal if the value is 
65%.

c. MAXIMAL VOLUNTARY VENTILATION (MAXIMUM BREATHING CAPACITY)

1. Set the drum speed at 10 mm/sec
2. Record one to two normal tidal volume
3. Breath as deeply and as rapidly as the subject can for 12 seconds. Ideally 90-110
breath/min.
4. Horizontal lines are drawn pass through most of the inspiratory and expiratory
peaks. The distance between these lines represents the average volume ( 1 mm =
30 ml) and this is multiplied by the number of breaths in the 12 seconds period.
This result in turns multiplied by 5/1000 so that the asnwer is expressed in L/min
5. An MVV/(40x FEV1) x 100% <75% indicates that the MVV is low relative to the FEV1,
and suggests neuromuscular disease or poor effort.

Table 1. Equations for lung volumes and ventilatory flows for adults aged 18–70 year

Variable Equation for Male Equation for Female

FVC prediction [27.63 – (0.112 x age)]x height [21.78 – (0.101 x age)] x
(cm) height (cm)
FEV1 prediction 0,037x height (cm) – 0,028x 0,028 x height (cm) – 0,021x
age (years) – 1,59 age (years) – 0,86
FEF25-75% prediction 1.94 x height (m) - 0.043x Age 1.25 x height (m) - 0.034 x age
+ 2.70 + 2.92

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Table 2. Normal Value of FVC of Indonesian for Male (The Pneumobile Project Indonesia)

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Table 3. Normal Value of FVC of Indonesian for Female (The Pneumobile Project Indonesia)

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Table 4. Normal Value of FEV1 of Indonesian for Male (The Pneumobile Project Indonesia)

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Table 5. Normal Value of FEV1 of Indonesian for Female (The Pneumobile Project Indonesia)

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REFERENCE
1. Brusasco V, Crapo R and Viegi G. 2006. Standardisation of Spirometry. Eur Respir J
26:319-338.
2. Ganong WF. 2003. Review of Medical Physiology 21st ed. Lange, Los Altos.
3. Miller MR, Crapo R, Hankinsin J, Brusasco V, Burgos F, Casaburi R, Coates A, van der
Grinten CPM, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D,
Pedersen OF, Pellegrin R, Viegi G and Wanger J. 2005. General considerations for lung
function testing. European Respiratory Journal. 26:153-161.
4. Tortora GJ and Derrickson BH. 2009. Principles of Anatomy and Physiology 12 th ed.
John Wiley & Sons, New Jersey.
5. West JB. Pulmonary pathophysiology. 8th edition. 2013
6. Crapo RO. Pulmonary function testing. 1994
7. Mangunnegoro H, Alsagaff H, Bernstein R, Johnson L, et al. Nilai-Normal-Faal-Paru-
Indonesia. Pneumobile.pdf. 1992.
8. Altman MA. Pulmonary function testing [Internet]. Third Edit. Diffuse Lung Disease: A
Practical Approach: Second Edition. Mosby, Inc.; 2012. Available from:
http://dx.doi.org/10.1016/B978-0-323-05267-2.00091-1
9. Quanjer, G.J. Tammeling, J.E. Cotes, O.F. Pedersen, R. Peslin, J-C. Yernault. 1993. Lung
volumes and forced ventilatory flows. European Respiratory Journal. 1993 6: 5-40
10. R. Pellegrino, G. Viegi, V. Brusasco, R.O. Crapo, F. Burgos, R. Casaburi, A. Coates,
C.P.M. van der Grinten, P. Gustafsson, J. Hankinson, R. Jensen, D.C. Johnson, N.
MacIntyre, R. McKay, M.R. Miller, D. Navajas, O.F. Pedersen and J. Wanger. 2005.
SERIES ‘‘ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING’’.
Interpretative strategies for lung function tests. European Respiratory Journal. 26:
948–968
11. Pefura-Yone EW, Kengne AP, Tagne-Kamdem PE, et alClinical significance of low forced
expiratory flow between 25% and 75% of vital capacity following treated pulmonary
tuberculosis: a cross-sectional studyBMJ Open 2014;4:e005361. doi:
10.1136/bmjopen-2014-005361)

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WORKSHEET LUNG FUNCTION TEST

IDENTITY ROOM
Name : Temperature : C
Sex : Humidity : %
Ras : Air pressure : mmHg
Age : year Position :
Height : cm
Weight : kg

RESULTS
PREDICTION RESULT
FVC prediction (based on equation):
Male :[ 27.63 – (0.112 x age)] x height (cm)
Female:[21.78 – (0.101 x age)] x height (cm)
FVC prediction (pneumobile)
FEV1 prediction (based on equation):
Male : 0,037x height (cm) – 0,028x age (years) – 1,59
Female; 0,028 x height (cm) – 0,021x age (years) –
0,86
FEF25-75% prediction (based on equation):
Male = 1.94 x height (m) - 0.043x Age + 2.70
Female = 1.25 x height (m) - 0.034 x age + 2.92
MVV prediction
= FEV1 x 40

No PARAMETERS RESULT 1 RESULT 2 RESULT 3

1 Tidal Volume (mL) Average:
2 IRC (mL) Average:
3 IC (mL) Average:
4 ERV (mL) Average:
5 VC (mL) Best:
6 FVC (mL) Best:
7 FVC/FVC prediction (%) Equation: Interpretation:
Pneumobile: Interpretation:
8 FEV1 (mL) Best:
9 Ratio FEV1/FVC (%) Interpretation:
10 FEV1/FEV1prediction (%) Equation: Interpretation:
Pneumobile:
11 FEF25-75% (L/s)

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 12 FEF25-75%/FEF25-75% Interpretation:
prediction
13 MVV (L)
14 MVV/(FEV1 x 40) Interpretation:

CONCLUSION:
1. Acceptable/not acceptable and reproducible/not reproducible
2. normal/restriction/obstruction/mix restriction-obstruction

FEEDBACK:

Instructor, Student,

( ) ( )

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