Evaluate My Lung

Pulmonary Evaluation & Optimisation
of a patient with Lung Disease.

Clinical Importance of PFTs
Dr Pavan Gurha
HOD, Anesthesiology & Critical Care
Batra Hospital, New Delhi
• The decision to have surgery is often not straightforward, as potential
long-term benefit comes with upfront risk of morbidity and mortality.
Br J Anaesth. Editorial Dec. 2016;117:681-4
• Minimizing that upfront risk and ensuring that patients understand

the trade-offs are critical components of high-quality preoperative
care.
PG Assembly- GB Pant -22nd Feb 2018 2

• Surgical risk refers to a probability of morbidity and
mortality during and after the surgery.
• The total risk associated with an operation can be

conceptualized as consisting of two mutually exclusive
components:
• Intrinsic risk and
• Modifiable risk

Aims of Preoperative Evaluation
•One primary reason for performing preoperative
evaluations is to make surgery safer- to reduce
modifiable risk.
•Diagnostic tests capable of identifying modifiable
risk or
•Therapeutic interventions capable of reducing
modifiable risk
•Estimating the total risk and communicating that
to patient

Post-operative pulmonary complications (PPCs)
• Remain a major cause of morbidity and mortality for patients undergoing surgery and
anesthesia.
• More frequent than cardiac complications.
• Incidence 5-10% in major noncardiac procedures.
• Up to 22% in high risk pts.
• 25% of deaths within a week of surgery – related to pulm. complications
• Post-operative pulmonary complications (PPCs) include

• Major
• Respiratory failure
• Mechanical ventilation
• Intubation > 48 h
• Minor
• Purulent tracheobronchitis
• Atelectasis
• Bronchospasm

Risk Factors for Post-operative pulmonary
complications
Patient Risk Factors
• Pre-existing pulmonary disease (COPD, ? Asthma, Interstitial lung Disease)
• Obstructive Sleep Apnea
• Pulmonary-Hypertension
• Heart Failure
• Poor Functional status
• Hypoalbuminemia (< 3 g/dL)
• Smoking (current or > 40 pack yrs)
• Age > 70 yrs
• BMI > 40
• Chronic alcohol intake > 60 g/day

Risk Factors for Post-operative pulmonary
complications
• Surgery related factors
• Prolonged Surgeries > 3 hrs
• Thoracic , upper abdominal surgery (↓ FRC, VC, diaphragmatic dysfxn
→ hypoxia & atelectasis)
• Emergency surgery
• Use of NG tube
• Anaesthesia –related
• GA (↓ FRC, inhibition of mucociliary clearance & surfactant production) →
Atelectasis
• Use of NMBs → Residual NMB → Cough reflex depressed → microaspiration
of gastric contents
• Atelectasis + Transient Resp M dysfunction → ↑ WOB

Preoperative Evaluation of the Patient with
Pulmonary Disease
• History and physical examination (based on the cardiopulmonary system)→
Single most useful tool
↓
• Basis for further diagnostic evaluation if needed.
• H/o Cough & expectoration
• Breathlessness
• Smoking
• Exercise tolerance
• Physical Exam for evidence of infection, bronchospasm, RHF

Preoperative tests
• Preoperative tests may be indicated for

(1) discovery or identification of a disease or disorder that
may affect perioperative anesthetic care;
(2) verification or assessment of an already known
disease, disorder, medical or alternative therapy that may
affect perioperative anesthetic care; and
(3) formulation of specific plans and alternatives for
perioperative anesthetic care.
ASA Practice advisory for preanesthesia evaluation - 2012

Routine investigations
• Hb, PCV, TLC, DLC, Platelets
• BS
• BU, S.Cr
• Na+, K+
• LFT ( S. Alb)
• ECG

Special tests
• X ray chest
• ABG- Pt’s history suggests hypoxemia or CO2 retention.
• Echocardiography- To assess PA press, RV fxn, TR in pts with PAH; LV
fxn, valvular or cong hrt ds.
• Pulmonary Function Tests

Pulmonary Function Tests
Term used to indicate a group of studies or maneuvers that may be
performed using standardized equipment to measure lung function
 Indications for PFTs

 Diagnostic
‾ To measure effect of disease on pulmonary function (obstructive or
restrictive )
 Screen individuals with pulmonary risk factors
 Preoperative risk assessment ( smoker, thoracic sx, abdominal sx,
morbidly obese )
• To asses prognosis ( lung transplant, pneumonectomy)
• Monitoring
- To asses reversibility with therapeutic intervention
(bronchodilator therapy, steroid treatment )

Limitations of PFTs
• Interindividual variability in normal predictive value
• Proper performance of test requires trained technician

and cooperation by patient
• Can not be used as single diagnostic test for a

particular disease

BED SIDE PULMONARY FUNCTION TESTS
Sabrasez Breath Holding Time

• A BHT> 40 sec is normal
• A BHT between 20-30 sec indicates compromised
cardiopulmonary reserve
• < 20 sec indicates poor cardiopulmonary reserve
Snider’s Match blowing Test

• Ability to blow the match off at 22 cm from mouth
indicates MBC>150L/min
De Bono’s whistle test

Spirometry
• Amongst many PFTs from which to choose
spirometry is the most useful, cost-effective, and
commonly used test.
• Measures the volume of air an individual inhales
or exhales as a function of time.
• Screening spirometry yields VC, FVC, and FEV1.
• From these values, two basic types of
pulmonary dysfunction can be identified and
quantitated –
Obstructive defects and
Restrictive defects.

Spirometry
• Measures VC, FVC, FEV1, PEFR.

• Can’t Measure – FRC, RV, TLC
• Tidal volume – volume of gas that moves in and out of the lungs during
quiet breathing (6-8ml/kg)
• Inspiratory reserve volume – maximum volume of air inhaled from the
end inspiratory tidal position (3200- 3500ml)
• Expiratory reserve volume – maximum volume of air that can be exhaled
from resting end expiratory tidal position (800-1200ml)
• Residual volume – volume of air remaining in lung after maximal
exhalation. Indirectly measured (FRC-ERV).(1500-2000)

Spirometry
• Inspiratory capacity – largest volume of gas that can be inspired

from the resting expiratory level(2500-3000 ml)
• Vital capacity-
- Maximum volume of air that can be exhaled starting from
maximum inspiration. 60ml/kg (3000-4000 ml)
- Correlates well with the capability for deep breathing and
effective coughing.
Decreased by restrictive pulmonary disease
• A vital capacity of at least three times the TV is necessary for an
effective cough.
• A vital capacity of <50% of predicted or <2 L is an indication of
increased risk.

Lung Volumes

Dynamic Lung Function Tests
 Forced Vital Capacity (FVC)
 Max Mid Expiratory Flow 25-75% (MMEFR)
 Peak Expiratory Flow (PEFR)
 Maximum Voluntary Ventilation (MVV) (Max

Breathing Capacity)

Forced Vital Capacity (FVC)
• The volume of gas that can be expired as forcefully and rapidly as

possible after maximal inspiration.
• Normally, FVC is equal to VC.
• Forced expiration ↑gas trapping→ FVC may be ↓ in COPD even
when VC appears normal.
• FVC is nearly always decreased by restrictive diseases.
• FVC values <15mL/kg are ass. with an ↑ incidence of PPCs, probably
because these patients cough ineffectively.

Forced Expiratory Volume in first second
(FEV1)
• Decreased FEV1 values are common in both obstructive and restrictive
disease patterns.
• The most important application of FEV1 is its comparison with the
patient’s FVC (FEV1 /FVC ).
• The FEV1 is normally ≥ 75% of the FVC.
• Patients with obstructive disease will exhibit a reduced FEV1 /FVC in
most cases.
• However, patients with restrictive disease usually have normal
FEV1/FVC

Maximum Mid Expiratory Flow Rate
• FEF25-75% is the average forced expiratory flow during the middle half
of the FEV maneuver.
• ↓ flow rates from this middle 50% of FVC represents flow in
medium size airways → indicative of obstructive disease of medium
size airways.
• Although somewhat effort-dependent, the test is much more reliable
and reproducible than FEV1/FVC.

Maximum Voluntary Ventilation (MVV)
• Largest volume of gas that can be breathed in 1 minute by voluntary

effort.
• Best ventilatory endurance test that can be performed in the
laboratory.
• Increases air trapping and exerts the ventilatory muscles,
• MVV is decreased greatly in patients with moderate to severe
obstructive disease.
• MVV is usually normal in patients with restrictive disease.

Reversibility of Airflow Obstruction
• A 12–15% increase in FEV1 and/or FVC is necessary to define

a meaningful response. FEV1 /FVC ratio is not used
• Lack of a response to bronchodilator testing in a laboratory

does not preclude a clinical response to bronchodilator
therapy

Functional Residual Capacity
• It is the volume of gas in the lungs at the end of a

normal tidal volume exhalation.
• FRC = RV + ERV
• Generally 1.8-2.2L
• The FRC and residual volume must be measured

indirectly because residual volume cannot be removed
from the lung.

Nitrogen washout test
• Having the subject breathe 100% O2 for several minutes so that

alveolar N2 is gradually “washed out”, the volume of gas and the
concentration of N2 in the exhaled gas are measured.
• FRC is calculated using the equation:

FRC = N2 volume x (N2)f / (N2)i
• Where (N2)i and (N2)f are the fractional concentrations of alveolar

N2 at the beginning and end of the test, respectively.

Flow Volume Loops
• Graphically demonstrate the flow

generated during a forced expiratory
maneuver followed by a forced
inspiratory maneuver, plotted against
the volume of gas expired
• Although various numbers can be

generated from the flow-volume
loops, the configuration of the loop
itself is probably the most informative
part of the test.

Flow Volume Loops- ? superseded
• Flow- volume loops were formerly useful in the diagnosis of large

airway and extrathoracic airway obstruction prior to the availability
of precise imaging techniques.
• Imaging techniques e.g. MRI give more precise and useful
information in the diagnosis of upper airway and extrathoracic
obstruction and have superseded the use of flow-volume loops for
diagnosis of these conditions.
Barash 2013, pg 280

Carbon monoxide diffusing capacity (DLCO)
• Collectively measures factors that affect the diffusion of gas across

the alveolar-capillary membrane.
• Recorded in mL CO/min/mmHg at STPD (standard temperature and
pressure, dry).
• Several methods for determining DLCO -all measure diffusing capacity
according to the equation:
mL CO transferred/min
• DLCO =______________________
Mean Paco2 – mean capillary Pco2
• The average value for resting subjects when the single-breath

method is used is 25mL CO/min/mmHg.
• DLCO values can increase 2-3 times normal during exercise.

Carbon monoxide diffusing capacity (DLCO)
• Decreases in DLCO
Obstructive lung disease
Parenchymal lung ds e.g. ILD, sarcoidosis, asbestosis etc.
Pulm involvement in syst ds e.g. SLE, RA
CV ds – Ac MI, MS, PPHt, Pulm edema, PE etc.
• Increases in DLCO
Polycythemia,
L→ R shunt,
Exercise

Clinical Importance of PFTs
• For patients who will have lung resection, pulmonary function testing
does provide some predictive benefit.
• For all other patients however, overwhelming evidence suggests that
preoperative pulmonary function testing does not predict or assign
risk for PPCs.
• Obtained to ascertain the

• Presence of reversible pulmonary disease (bronchospasm) or
• To define the severity of advanced pulmonary disease.

Assessment of Respiratory Function in the
Thoracic Surgery Patient
• Clear ass. between extent of lung resection and periop morbidity &
mortality
• Mortality after Pneumonectomy > (2-3 X) Lobectomy >
Segmentectomy
• Best assessment of resp fxn- from history of patient’s quality of life.
• Objective measures of pulmonary function-
(i) Respiratory mechanics
(ii) Lung parenchymal fxn (gas exchange)
(iii) Cardiopulmonary interaction
• The purpose of these is to assess the movement of O2

• Into the alveoli
• Into the Blood, and
• Into the tissues

I. Respiratory Mechanics
Many tests show correlation with post-thoracotomy outcome
 FEV1
 FVC
 MVV,
 Residual volume/total lung capacity ratio (RV/TLC)
 Of these, the most valid single test for post-thoracotomy respiratory

complications is the predicted postoperative FEV1 (ppoFEV1%), which is
calculated as follows:
ppoFEV1% = preoperative FEV1%
X (1-% functional lung tissue removed/100)

Method of estimating the % of functional
lung tissue
• Based on number of functioning
subsegments of the lung
removed.
• Pts with a ppoFEV1 > 40% - low
risk for PPCs.
• Risk of major respiratory
complications is ↑ with a
ppoFEV1 < 40%
• Pts with ppoFEV1 < 30% are at
high risk.

II. Lung Parenchymal function
 Traditionally, ABG data e.g. PaO2 < 60 mm Hg or PaCO2 > 45 mm Hg - cut
off values for pulmonary resection.
 The most useful test of the gas exchange capacity of the lung is the
diffusing capacity for carbon monoxide (DLCO).
 The DLCO correlates with the total functioning surface area of the
alveolar-capillary interface.
 The corrected DLCO →calculate a postresection (ppo) value
 A ppoDLCO < 40% correlates with ↑ respiratory and cardiac
complications.

ppoDLCO & POSTOP MORBIDITY
 DLCO, (but not FEV1) is negatively

affected by preop chemotherapy
 National Emphysema Treatment

Trial- patients with a ppoFEV1 or
DLCO < 20% - unacceptably high
periop mortality rate.
 Considered as the absolute

minimal values compatible with
successful outcome.

III. Cardiopulmonary Interaction
• Formal lab exercise testing(Cardio-Pulmonary Exercise Testing) – ‘gold
standard’ for assessment of cardiopulmonary function
• Useful tool for detecting overt and occult exercise-induced myocardial
ischemia. Superior to standard ECG stress testing
Brunelli A et al. ACCP Guidelines. CHEST 2013;143(5): e166S-e190S
• Maximal O2 consumption (VO2max) -most useful predictor of post-
thoracotomy outcome.
• Normal VO2max at 25 yrs: Males- 45 mL/kg/min; Females- 40 mL/kg/min
• Morbidity & mortality - unacceptably high if the preop VO2max <
15 mL/kg/min.
• pts with VO2max > 20 mL/kg/min have few respiratory complications; fit for
any resection incl pneumonectomy
• 1 MET= metabolic equivalent = 3.6 mLO2/kg/min.(Amount of O2 consumed
while sitting at rest)

ACCP Guidelines for physiological evaluation of patients
with lung cancer for lung resection- 2013
• All patients for lung cancer surgery should have PPO FEV1 and DLCO
calculated:
• If PPO FEV1 and DLCO are>60% predicted→ no further tests
• If PPO FEV1 and DLCO are 30- 60% predicted→ low technology
exercise test [stair climb test (SCT)/ shuttle walk test (SWT)]
• Pts who walk < 25 shuttles (400 m) or climb < 22 m → Formal CPET
with measurement of VO2 max
• If PPO FEV1 and DLCO are < 30% predicted → Formal CPET with
measurement of VO2 max
• If VO2 max < 10ml/kg/min (< 35% predicted) → Consider minimally
invasive surgery, sublobar resections or nonoperative Tt options

Physiological evaluation algorithm for lung
resection-
ACCP 2013
• Low risk- Mortality < 1%; High risk- mortality > 10%
• Moderate risk- Morbidity & Mortality varies with split lung fxn, exercise
tolerance & extent of resection

Preoperative assessment → Postop
management

CPET and ‘low-technology’ exercise testing
• An exercise test is recommended for all patients posted for lung

cancer surgery with a PPO FEV1 and DLCO < 60%
• Formal CPET is the procedure of choice, and
• VO2 max is the single most important parameter
• However, CPET is often not available → Interest in ‘low-tech’ exercise
testing
• Stair climbing
• 6 MWT

Cardiopulmonary Interaction- Stair
climbing
• Done at the patient's own pace but without stopping
• Ability to climb 5 flights –
VO2max > 20 mL/kg/min,
• Climbing two flights - VO2max of 12 mL/kg/min.
• A patient unable to climb two flights is at extremely high risk.
• ‘Flight’ - 20 steps at 6 inches/step

Cardiopulmonary Interaction- 6 minute walk test
(6MWT)
• Excellent correlation with VO2max

• Requires little or no laboratory equipment.
• VO2max can be estimated from 6MWT distance in meters divided by 30

eg; 600 mts = VO2max of 20 mL/kg/min
• Patients with a ↓ of SpO2 > 4% during exercise (stair climbing 2-3

flights or equivalent) are at ↑risk.

Ventilation-Perfusion Scintigraphy
• Prediction of postresection pulmonary function can be further

refined by assessment of the preoperative contribution of the lung or
lobe to be resected using ventilation-perfusion lung scanning
• If the lung region to be resected is nonfunctioning or minimally
functioning, the prediction of postoperative function can be modified
accordingly.
• Particularly useful in pneumonectomy patients
• V/Q scanning recommended→ any pneumonectomy patient who
has a preoperative FEV1 and/or DLCO < 80%.(i.e. ppo < 40%)

Split-Lung Function Studies
• To simulate the postoperative respiratory situation by

• Unilateral exclusion of a lung or lobe with an endobronchial
tube/blocker or
• By pulmonary artery balloon occlusion of a lung or lobe artery
• Not shown sufficient predictive validity for universal adoption in lung
resection patients
• For the present, split-lung function studies have been replaced in
most centers by a combined assessment of
• Spirometry,
• DLCO,
• Exercise tolerance, and
• Scanning.

Cardiovascular Risk in lung resection
• Pts with lung Ca → atherosclerotic cardiovascular disease → cigarette

smoking
• Underlying CAD – 11- 17%
• Risk of major postop cardiac complications (myocardial ischaemia,
PE, VF/ cardiac arrest, complete heart block → 2-3% after lung
resection
• Preop cardiac risk assessment using Revised Cardiac Risk Index
(RCRI) as a screening tool to identify pts requiring specialized preop
cardiac testing - AHA/ACC Guidelines
• The RCRI has been recalibrated for the lung resection population –
Thoracic RCRI.

Thoracic RCRI (ThRCRI)
• Four-class risk score

1. IHD : Any of the following- H/o MI / +ve exercise test/ current
chest pain, nitrate therapy/ECG with pathological Q waves (Score = 1.5
points)
2. H/o cerebrovascular disease (TIA/stroke) - Score = 1.5 points
3. S. Creatinine > 2mg/dL - Score = 1 point
4. Pneumonectomy - Score = 1.5 points
• Patients with
• ThRCRI ≥ 2
• Unable to climb 2 flights of stairs
• Heart condition – newly diagnosed/ requiring Tt
should be referred for cardiological evaluation

Comorbities affecting Perioperative
Outcomes
• CV disease- CHF, IHD, Arrythmia etc. – second most common cause of
periop morbidity & mortality
• Obstructive sleep apnea
• Pulmonary Hypertension
• Renal dysfunction
• Malnutrition

Preoperative optimization of a patient with lung
disease
• Smoking
• ↑ CoHb levels,
• ↓ ciliary fxn
• ↑ sputum production
• Nicotine → Stimulation of CVS (↓ coronary flow reserve, vascular endothelial
dysfxn, HT, ischemia)
• Smokers –
• ↑ wound infections,
• respiratory or airway complications (including desaturation)
• severe coughing.
• longer hospital stays
• often need postoperative intensive care admission.

Cessation of smoking
• Single most important intervention
• Soon after a patient quits smoking,
• CO levels ↓ → Improves O2 delivery & utilization.
• Cyanide levels ↓ → benefits mitochondrial oxidative
metabolism.
• ↓ nicotine levels improve vasodilation
• Improved mucous clearance
Smoking cessation for at least 4-8 wks necessary to ↓ PPCs.

Use of Nicotine transdermal patches – controversial.

disease
• Antibiotics for chest infection-
Gram's stain of the sputum and blood cultures.
• Bronchodilator therapy- even in the absence of bronchospasm

Inhaled/ systemic steroids- ↓ the incidence of bronchospasm
• Chest physiotherapy for

-Removing secretions from the bronchial tree →postural
drainage, vigorous coughing, chest percussion
- Lung expansion manoeuvres- deep breathing and incentive
spirometry
- Familiarisation with respiratory therapy equipment

disease
• Correction of hypovolemia and electrolyte imbalance - adequate
hydration decreases the viscosity of bronchial secretions and
facilitates their removal from the bronchial tree.
• Humidification of inspired gas is extremely useful.

• Mucolytic drugs, such as acetylcysteine , or oral expectorants
(potassium iodide) - beneficial to patients with viscous secretions.
• CPAP in OSA pts
• In pts with Cor pulmonale- Diuretics, digitalis, supplemental O2
• DVT prophylaxis
• Discuss Postop analgesia plan with pt

Conclusions
• Patients with lung disease presenting for non thoracic surgery have a
high risk of developing PPCs.
• The risk significantly increases if these patients require thoracic
surgery.
• Detailed history & physical examination → single most useful tool in
preoperative evaluation
• In patients undergoing lung resection → FEV1 , DLCO ,and CPET form
the ‘three legged stool’ of pre-thoracotomy resp assessment.
• A cardiopulmonary assessment is very important for thoracic surgery.
Other comorbidities e.g. OSA, PAH, malnutrition need to be looked
for and appropriately managed.
• Preop optimisation e.g. cessation of smoking, antibiotics,
bronchodilators, steroids, chest physiotherapy, hydration etc
significantly improve periop outcomes.

Thank you!

Evaluate My Lung

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Evaluate My Lung

Uploaded by

Copyright:

Available Formats

Pulmonary Evaluation & Optimisation

of a patient with Lung Disease.

• Minimizing that upfront risk and ensuring that patients understand

PG Assembly- GB Pant -22nd Feb 2018 2

• The total risk associated with an operation can be

PG Assembly- GB Pant -22nd Feb 2018 3

PG Assembly- GB Pant -22nd Feb 2018 4

• Post-operative pulmonary complications (PPCs) include

PG Assembly- GB Pant -22nd Feb 2018 5

PG Assembly- GB Pant -22nd Feb 2018 6

PG Assembly- GB Pant -22nd Feb 2018 7

PG Assembly- GB Pant -22nd Feb 2018 8

• Preoperative tests may be indicated for

PG Assembly- GB Pant -22nd Feb 2018 9

PG Assembly- GB Pant -22nd Feb 2018 10

PG Assembly- GB Pant -22nd Feb 2018 11

 Indications for PFTs

PG Assembly- GB Pant -22nd Feb 2018 12

• Proper performance of test requires trained technician

• Can not be used as single diagnostic test for a

PG Assembly- GB Pant -22nd Feb 2018 14

Sabrasez Breath Holding Time

Snider’s Match blowing Test

PG Assembly- GB Pant -22nd Feb 2018 15

PG Assembly- GB Pant -22nd Feb 2018 16

• Measures VC, FVC, FEV1, PEFR.

PG Assembly- GB Pant -22nd Feb 2018 17

• Inspiratory capacity – largest volume of gas that can be inspired

PG Assembly- GB Pant -22nd Feb 2018 18

PG Assembly- GB Pant -22nd Feb 2018 19

 Forced Vital Capacity (FVC)

 Max Mid Expiratory Flow 25-75% (MMEFR)

 Peak Expiratory Flow (PEFR)

 Maximum Voluntary Ventilation (MVV) (Max

PG Assembly- GB Pant -22nd Feb 2018 20

• The volume of gas that can be expired as forcefully and rapidly as

PG Assembly- GB Pant -22nd Feb 2018 21

PG Assembly- GB Pant -22nd Feb 2018 22

PG Assembly- GB Pant -22nd Feb 2018 24

• Largest volume of gas that can be breathed in 1 minute by voluntary

PG Assembly- GB Pant -22nd Feb 2018 25

• A 12–15% increase in FEV1 and/or FVC is necessary to define

• Lack of a response to bronchodilator testing in a laboratory

PG Assembly- GB Pant -22nd Feb 2018 26

• It is the volume of gas in the lungs at the end of a

• The FRC and residual volume must be measured

PG Assembly- GB Pant -22nd Feb 2018 27

• Having the subject breathe 100% O2 for several minutes so that

• FRC is calculated using the equation:

• Where (N2)i and (N2)f are the fractional concentrations of alveolar

PG Assembly- GB Pant -22nd Feb 2018 28

• Graphically demonstrate the flow

• Although various numbers can be

PG Assembly- GB Pant -22nd Feb 2018 29

• Flow- volume loops were formerly useful in the diagnosis of large

PG Assembly- GB Pant -22nd Feb 2018 31

• Collectively measures factors that affect the diffusion of gas across

• The average value for resting subjects when the single-breath

PG Assembly- GB Pant -22nd Feb 2018 32

PG Assembly- GB Pant -22nd Feb 2018 33

• Obtained to ascertain the

PG Assembly- GB Pant -22nd Feb 2018 34