REVIEW

Pulmonary Function Test: Spirometry

Duu Wen Sewa, MRCP (UK), Thun How Ong, MRCP (UK)
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore

ABSTRACT

Spirometry is a useful tool in assessing the physiological lung function of a patient, and can be helpful in
differentiating the etiology of the patient’s symptoms. Indications for the test and the actual procedure are as
described. Validity of a spirometry depends on patient co-operation and criteria for acceptability and repeatability
must be met for useful interpretation of the results. Commonly measured parameters are described and a simple
logarithm for interpretation of a spirometry result is given. Physicians must be mindful when interpreting
the result in the context of extreme of ages, size or differing ethnicity as reference values for these groups of
individuals are often extrapolated and not validated.

Keywords: central airway obstruction, obstructive pulmonary disease, spirometry

INTRODUCTION patients with pain, nausea or other discomfort, as

Pulmonary function testing comprises of mainly
three components: spirometry, lung volumes and
diffusing capacity. Spirometry, from the Latin spiro
“to breathe” and the Greek metron “measure” is
one of the oldest and most commonly ordered
tests of pulmonary function. It is a physiological
test that measures how an individual inhales or
exhales volume of air as a function of time. It is a
valuable tool for evaluating the respiratory system,
representing an important adjunct to the patient
history, various lung imaging studies and invasive
testing.
INDICATIONS FOR SPIROMETRY
The clinical indications for spirometry are varied
and depend on the clinical settings and questions
to be addressed. Generally accepted clinical
indications are listed in Table 1.
Spirometry has very few absolute contra-
indications, although several conditions may raise
caution and others may affect the quality of results.
It is recommended that test not be performed
within one month of an acute coronary syndrome
or myocardial infarction1, or in pregnancy. Similarly,
well as altered mental state may not be able to co-
operate fully, giving suboptimal results.
Testing Procedure
Spirometry requires a voluntary maneuver in which
a patient inhales maximally from tidal breathing at
rest to total lung capacity (TLC) and then rapidly
exhales to the fullest extent until no further volume
is exhaled at residual volume (RV), followed by a
maximum inspiration back to TLC (Fig. 1). A volume
vs. time plot and a flow vs. volume plot for the same
maneuver can be generated as shown in Fig. 2. The
maximal flow-volume curve is helpful in quality
assurance, in detecting mild airflow obstruction,
and in detecting central airway obstruction. For
best results, both inspiratory and expiratory loops
are obtained.
Acceptability and Repeatability Criteria
A number of spirometry standards have been
developed over the years1–3. The pulmonary
function lab at Singapore General Hospital and
most other testing centres in Singapore use
the American Thoracic Society and European

Proceedings of Singapore Healthcare  Volume 23  Number 1 2014 57

 Table 1: Indications for Spirometry
Diagnostic
To evaluate symptoms and/ or signs pertaining to respiratory system e.g chronic cough, dyspnea,wheezing etc
To measure the effect of disease on pulmonary function
To screen individuals at risk of having pulmonary disease
To assess pre-operative risk
To assess prognosis of patients with respiratory disease
To assess health status before beginning strenuous physical activity programme
Monitoring
To assess therapeutic intervention
To describe the course of disease that affect lung function
To monitor people exposed to injurious agents
To monitor for adverse reactions to drugs with known pulmonary toxicity
Disability/ impairment evaluations
To assess patients as part of a rehabilitation programme
To assess risks as part of insurance evaluation
To assess individuals for legal reasons

Volume (L) Inspiratory

Reserve
IRV
Inspiratory Volume
VC Capacity (ERV)
(IC) Vital Tidal
VT Capacity Volume Total
(VC) (TV) Lung
Expiratory Capacity
Reserve (TLC)
ERV
Volume Functional
FRC (ERV) Residual
Capacity
Residual Residual (FRC)
RV Volume Volume
(RV) (RV)

Time (sec)
Fig. 1. Static lung volume measurements
Volume

Flow

Time Volume

Fig. 2. Volume vs time and flow vs. time plots

Respiratory Society (ATS/ERS) Task force criteria for if at all.

acceptability and repeatability (see Table 2).
Reference values
Failure to achieve this criterion means that the The interpretation of various spirometric indices
spirometry must be interpreted with caution, is based on comparisons of data measured in an

58 Proceedings of Singapore Healthcare  Volume 23  Number 1  2014

 Spirometry

Table 2: Acceptability criteria for Spirograms4

Good start (extrapolated volume <5% of FVC or 0.15L, whichever is greater)5

Absence of artefacts (refer Fig.3) such as
a) submaximal effort at any point
b) obstructed mouthpiece
c) coughing
d) early termination or cutoff
e) glottis closure influencing measurement
f ) leak
Satisfactory exhalation
Duration ≥ 6s in adults or plateau in volume-time curve or if subject cannot continue to exhale

Between-maneuver criteria:
Once 3 acceptable spirograms are obtained, apply the following:
Two largest value for FVC must be within 0.15 L of each other
Two largest value for FEV1 must be within 0.15L of each other
If both of the above are met, testing session may be terminated
If not, continue testing until:
Both criteria are met with additional maneuvers performed OR
Total of eight tests have been performed OR
The patient is no longer able to or no longer wishes to continue

Normal Cough
Glottis closure

Hesitation
at start
Suboptimal effort

Fig. 3. Acceptable and unacceptable flow-volume loops

individual subject with reference values derived
from a representative population of health
subjects2,7–8. Normal values of pulmonary function
vary with age, height, gender and ethnicity.
Moreover, the range of normal is considerably
varied. These factors complicate the choice of
the most appropriate reference range regression
equations to use in the pulmonary laboratory9–12.
Additionally, because reference values are often
derive from populations with little representation
at the extremes of age and size, interpret these
ranges with caution. The ATS/ERS recommends
the use of the Third National Health and Nutrition
Examination Survey in the United States as a
spirometry reference standard in USA.

Proceedings of Singapore Healthcare  Volume 23  Number 1  2014 59

Review
Currently, there is no specific set of equations that
has been validated for Asian population. Specific
values for “normalcy” are controversial but in
general, there is a move towards reporting the
normal range in terms of a lower limit of normal
(LLN) and an upper limit of normal (ULN). 2005 ATS/
ERS recommended that the LLN be determined
from the fifth percentile (i.e. 1.96 SD: two-tailed t
test, p <0.05)13. In contrast, the Global Initiative for
Chronic Obstructive Lung Disease14 suggests using
a fixed cutoff of 0.70 for the post bronchodilator
FEV1/FVC to define obstruction. Both systems have
their limitations15–17.
Most important, spirometry values need to be
interpreted in the context of the patient, their
symptoms, and other testing for the highest yield
in diagnosis and management.
Commonly Measured Spirometric indices
Forced expiratory Volume in 1 sec (FEV1)
The FEV1 is the most widely used parameter to
measure the mechanical properties of the lungs,
i.e. we are measuring the “strength” of the patient’s
lungs. The absolute value of the FEV1 obtained by
the patient is then compared to his or her peers
according to age, gender, height, and ethnicity.
Spirometric values below the 5th percentile of
the frequency distribution of values measured
in the reference population are considered to be
below the expected “normal range” or below “the
lower limit of normal (LLN)”. The practice of using
80% predicted as a fixed value for the lower limit
of normal may be acceptable in children, but can
lead to important errors when interpreting lung
function in adults and as such is not recommended
by the ATS/ERS task force.13 FEV1 is decreased in
both obstructive and restrictive lung diseases.
Severity of most lung pathology (e.g. Chronic
Obstructive Pulmonary Disease or COPD) is based
on the percentage predicted FEV1 rather than the
absolute value of FEV118–20. Although there are good
evidence that FEV1 correlates well with severity
of symptoms and prognosis in many diseases21–22,
the correlates do not allow physicians to
accurately predict symptoms and prognosis in
individual patients.
Forced Vital Capacity (FVC)
FVC is a measure of lung volume and is usually
reduced in disease that causes the lungs to be
60 Proceedings of Singapore Healthcare  Volume 23  Number 1  2014
smaller e.g., restrictive lung disease, disorders
of the bellows (kyphoscoliosis, neuromuscular
weakness). The absolute FVC is compared with the
patient’s peers to obtain a percentage predicted
value. A reduction in FVC can also occur in situation
whereby the lungs are hyperinflated due to severe
obstruction and air trapping, and increased
residual volume, a phenomenon referred to as
pseudorestriction. Therefore, FVC is not a reliable
indicator of total lung capacity or restriction,
especially in the setting of airflow obstruction, and
lung volume measurements should be done when
a restrictive pattern is seen on simple spirometry.
FEV1 / FVC ratio
In healthy adults, this should be approximately
75–80%. FEV1/FVC ratio is measured using the
absolute values of FEV1/FVC rather than percentage
predicted. In obstructive diseases, FEV1 is reduced
due to airway resistance to expiratory flow; the
FVC may also be diminished due to premature
closure of airway in expiration, but not in the same
proportion as FEV1. This leads to a reduced FEV1/
FVC ratio. In restrictive disorders, the FEV1, FVC
and TLC are all reduced, and the FEV1 / FVC ratio is
normal or even elevated.
A ratio of FEV1/FVC of < 70% is generally taken to
indicate obstructive airways disease. Note should
be made, however, the as one ages (male >40yrs
and females >50yrs), the ratio of FEV1/FVC tend
to drop, and for elderly patients the lower limit of
normal (LLN) for FEV1/FVC may be a more useful
indicator of obstruction than an absolute value of
70%. Hence the ATS/ERS taskforce recommends the
use of the 5th percentile of the normal distribution
as cutoff for the lower limit of the reference range
(LLN)13 so as to avoid over-diagnosis of obstructive
lung disease.
One of the most common problems encountered
in spirometry is that patients are unable to exhale
completely (i.e. expiration time is <6 s or fails to
plateau; in this case the FVC is underestimated and
the FEV1/FVC ratio is overestimated, leading the
physician to wrongly conclude that the patient does
not have obstructive airways disease (see algorithm).
Flow-Volume Loop
The flow-volume loop is a plot of inspiratory and
expiratory flow (y-axis) against volume (x-axis)
during the performance of maximally forced
 Spirometry

a) 6 b) 6 c) 6

3 3 3
Flow L∙s-1

0 0 0

-3 -3 -3

-6 -6 -6
0 2 4 0 2 4 0 2 4
Volume L Volume L Volume L

Fig. 4. Flow-volume curves in physiologic central airway obstructions: a) fixed central airway obstruction. b) variable
extrathoracic obstruction. c) variable intrathoracic obstruction.

Pre-Bronch Post-Bronch

Pred LLN Actual % Pred Actual % Chng

––SPIROMETRY––

FEV1 (L) 2.80 1.89 0.68 24 0.68 0

FEC (L) 3.99 2.77 1.97 49 2.03 3

FEV1/FVC (%) 79 71 34 44 34 -2

10
8
6
4
2
2
0
1 2 3 4 5
-2
-4
-6
-8 -1 0 1 2 3 4 5 6 7
-10

Pred Pre Post

Fig. 5. Example of a spirometry of a patient with obstructive lung disease. Note the reduced FEV1/FVC ratio with decreased
FEV1. Flow-volume curve shows the typical scoop appearance in the expiratory loop.

inspiratory and expiratory maneuvers. The normal Typical flow-volume plots observed with differing
expiratory portion of the flow volume loop is types of physiologic central airway obstruction are
characterized by a rapid rise to the peak flow rate, shown in Fig. 4.
followed by a near linear fall in flow as the patient
exhales toward residual volume. The Inspiratory Case Studies: Common patterns of Abnormality
curve, in contrast, is a relative symmetrical, saddle Obstructive Airways Disease
shaped curve. (Examples: chronic obstructive lung disease,
asthma, cystic fibrosis, and bronchiolitis obliterans).
The shape of the flow-volume loop can indicate
the location of airflow limitation. In common A 67-year old smoker presented with cough and
obstructive airflow disorders e.g. asthma and wheeze. His spirometry is as follows: (see Fig. 5)
emphysema, early evidence of airflow obstruction is
qualitatively demonstrated by a concave “scooped- In normal patients, up to 70% of the vital capacity of
out” shape of the expiratory flow-volume curve. the lungs is emptied in the first second (hence FEV1/

Proceedings of Singapore Healthcare  Volume 23  Number 1  2014 61

Review

Pred LLN Actual % Pred

––SPIROMETRY––

FEV1 (L) 3.42 2.51 1.63 48

FEC (L) 4.31 3.09 1.72 40

FEV1/FVC (%) 84 76 94 112

10
8
6
4
2 2
0
-2 1 2 3 4 5
-4
-6
-8
-10

Pred Pm -1 0 1 2 3

Fig. 6. The spirometry of a patient with restrictive lung disease. The flow volume shape is maintained but there is a
proportional decrease in both FEV1 and FVC (normal FEV1/FVC ratio).

Assess acceptability,
repeatability criteria

YES

FEV1/FVC ratio

Ratio < LLN Ratio ≥ LLN

FVC< LLN FVC ≥ LLN

Restrictive lung Normal

Obstructive lung disease
disease

Confirm with lung

volume test

Fig. 7. A simplified algorithm in interpretation of spirometry results. LLN: lower limit of normal.

62 Proceedings of Singapore Healthcare  Volume 23  Number 1  2014


FVC ratio > 70%) With obstructive lung disease,
it takes longer for the lung to empty. Smaller
airways are narrower, resulting in lower flow with
sharp fall in the flow volume loop (scooped out
appearance). FEV1 and FEF (forced expiratory flow
at 25% to 75% of forced vital capacity) are low.
Typically, the patient will have a normal FVC,
though an incomplete expiration may falsely lower
this value, leading to an overestimation of the FEV1/
FVC ratio.
Note that spirometry only gives us the pattern of
lung function abnormality – in this case, obstructive
airways disease. It does not tell us if this patient has
asthma or COPD. The diagnosis will depend on the
patient’s clinical presentation and the spirometry
merely provides collaborative evidence.
Restrictive airway disease
(Examples: idiopathic pulmonary fibrosis,
hypersensitivity pneumonitis, and obesity).
A 55-year old woman, having a history of
rheumatoid arthritis, presenting with progressive
dyspnea on exertion and clinical findings of fine
inspiratory velcro-like crepitations at both lung
bases. (See Fig. 6).
Restrictive airway disease means that the total lung
volume is too low. Although an accurate diagnosis
of total lung volume is not possible with spirometry
(residual lung volume cannot be measured with
a spirometer) spirometry results can be very
suggestive for a restrictive lung disease.
Since the airways are normal, the flow volume loop
will have a normal shape: the curve will descend
in a straight line from the PEF to the x-axis. Total
lung volume is low, which results in a low FVC. PEF
(peak expiratory flow) can be normal or low. FEV1 is
equally lowered than FVC, so the FEV1/FVC ratio will
be normal or even raised.
A simple algorithm for interpretation of
spirometry results
(As seen in Fig. 7)
Related tests
Bronchodilator test
Reversibility test after administration of a
bronchodilator is frequently undertaken. Baseline
testing is done followed by administration of
a short-acting bronchodilator (i.e. salbutamol
Proceedings of Singapore Healthcare  Volume 23  Number 1  2014
Spirometry
400ug or ipratiopium 160ug). An increase in either
the FEV1 or the FVC of ≥12% AND ≥200ml is now
considered a “positive” bronchodilator response13.
Note that a positive bronchodilator test does
not have adequate sensitivity and specificity in
differentiating a patient with asthma from chronic
obstructive lung disease.23-25 In addition, response
well below the significant thresholds may still
be associated with improvement in the patient
symptoms and performance.26
Airway challenge test
Airway hyperresponsiveness (AHR) is one of
the characteristic features of asthma. Use of
an exogenous stimuli e.g. methacholine to
directly challenge the airway to elicit airway
responsiveness is a commonly performed test in
the diagnostic workup of a suspected asthmatic
patient. Methacholine responsiveness is usually
reported as the provocation concentration causing
a 20% decrease in the FEV1 (i.e. PC20).27 The results
are typically interpreted as followed: normal
PC20>16mg/mL; borderline PC20=4 to 16mg/
mL; mild AHR PC20=1 to 4mg/mL; moderate AHR
PC20=0.25 to 1mg/mL; and marked AHR PC20
<0.25mg/mL. From a diagnostic point of view, the
test has a strong negative predictive value, and
functions best when used to exclude a diagnosis
of asthma in a currently symptomatic patient.
False negative results can occur in the following
situation:
• Airway responsiveness may have been
suppressed by recent use of anti-inflammatory
medication;
• The patient is asymptomatic due to passing of
season for aeroallergen exposure28;
• Patients with occupational asthma may only
response when challenged with the specific
agent29.
On the other hand, bronchial hyperresponsiveness
may be seen in a wide variety of other diseases,
including smoking-induced chronic airway
obstruction, congestive heart failure, cystic fibrosis,
acute bronchitis, and allergic rhinitis30.
CONCLUSION
Spirometry is a useful and easy to perform test
to assess the physiological lung function of a
patient. Care must be taken to ensure that it is
63
Review
done with the proper equipment and correct
technique for maximal results. The clinician must
have an appreciation of the common pitfalls in
the performance, reporting and interpretation
of results so that he can apply the results to any
particular clinical scenario.
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