Pulmonary function tests

Pulmonary function tests
Standard pulmonary function tests measure airflow rates, lung volumes, and the ability of the lung to transfer gas across the alveolarcapillary membrane

Indications for pulmonary function testing
      Assessment of the type and extent of lung dysfunction; Diagnosis of causes of dyspnea and cough Detection of early evidence of lung dysfunction Follow-up of response to therapy Preoperative assessment; and disability evaluation Spirometry and measurement of lung volumes allow measurement of the presence and severity of obstructive and restrictive pulmonary dysfunction

Contraindications to pulmonary function testing
      Acute severe asthma Respiratory distress Angina aggravated by testing Pneumothorax Ongoing hemoptysis Active tuberculosis

Ventilatory function
The volume of gas in the lungs is divided into volumes and capacities

 Tidal volume (VT) is the amount of gas inhaled and exhaled with each resting breath  Residual volume (RV) is the amount of gas remaining in the lungs at the end of a maximal exhalation  Vital capacity (VC) is the total amount of gas that can be exhaled following a maximal inhalation  The vital capacity and the residual volume together constitute the Total lung capacity (TLC), or the total amount of gas in the lungs at the end of a maximal inhalation  Functional residual capacity (FRC) is the amount of gas in the lungs at the end of a resting tidal breath.

 The forced vital capacity (FVC) maneuver begins with an inhalation from FRC to TLC (lasting about 1 second) followed by a forceful exhalation from TLC to RV (lasting about 5 seconds)  The amount of gas exhaled during the first second of this maneuver is the forced expiratory volume in the first second (FEV1)  Normal subjects expel approximately 80% of the FVC in the first second

 Three measurements are commonly made from a recording of exhaled volume versus time  FEV1: The volume of gas exhaled during the first second of expiration  FVC: The total volume exhaled  FEF 25%-75% or maximal mid-expiratory flow rate MMFR: The average expiratory flow rate during the middle 50% of the VC  FEV1/FVC: 0.75 – 0.80

Obstructive dysfunction  Marked by a reduction in airflow rates  Fall in the ratio of FEV1 (forced expiratory volume in the first second) to FVC (forced vital capacity)  Causes include asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, bronchiolitis, and upper airway obstruction

Restrictive dysfunction
 Marked by a reduction in lung volumes  Normal to increased FEV1/FVC ratio  Severity is graded by the reduction in total lung capacity  Causes include decreased lung compliance from infiltrative disorders such as pulmonary fibrosis; reduced muscle strength from phrenic nerve injury, diaphragm dysfunction, or neuromuscular disease; pleural disease, including large pleural effusion or marked pleural thickening; and prior lung resection

Diffusing Capacity
 Measurement of diffusing capacity reflects the ability of the lung to transfer gas across the alveolar/capillary interface  It is assessed by diffusing capacity of the lung for carbon monoxide DLCO

Total pulmonary diffusing capacity depends upon: 1. Diffusion properties of the alveolarcapillary membrane 2. Amount of hemoglobin occupying the pulmonary capillaries
 *Corrected DLCO = Measured DLCO x where [Hb] is the measured hemoglobin concentration (g/dL).

Clinical Correlation
 Assessing disease affecting the alveolar-capillary bed or pulmonary vasculature

Causes of lowered DLCO :
     Interstitial lung disease Emphysema Pulmonary vascular disease Recurrent pulmonary emboli Primary pulmonary hypertension

Higher DL CO :

 Conditions of increased blood volume in pulmonary vasculature e.g. Congestive heart failure  Alveolar hemorrhage e.g. Goodpasture’s syndrome.




Flexible bronchoscopy
  1. 2. 3. 4. Essential tool in the diagnosis and management of many pulmonary diseases Indications: Evaluation of the airway Diagnosis and staging of bronchogenic carcinoma Evaluation of hemoptysis Diagnosis of pulmonary infections

Significance of Flexible Bronchoscopy
 It allows transbronchial lung biopsy  Bronchoalveolar lavage  Removal of retained secretions and foreign bodies from the airway

Contraindications  Severe bronchospasm or a bleeding diathesis Complications  Hemorrhage, Fever, Transient hypoxemia. Deaths are rare. Hospitalization for flexible bronchoscopy is not necessary

Rigid bronchoscopy
 Indications: 1.Massive bleeding 2.Extraction of large obstructing objects (foreign bodies, blood clots, tumor masses, broncholiths) 3.Biopsy of tracheal or main stem bronchus tumors and bronchial carcinoids 4.Facilitation of laser therapy

Significance of Rigid Bronchoscopy
Unlike flexible bronchoscopy, which can usually be performed with only topical anesthesia and low-dose conscious sedation (an opioid or a benzodiazepine or both), rigid bronchoscopy usually requires general anesthesia

Advances in techniques
1.Endobronchial laser therapy 2.Electrocautery 3.Tracheobronchial stenting 4.Endobronchial ultrasound guidance to locate lymph nodes prior to transbronchial needle aspiration biopsy

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