University of Gezira

Faculty of Medicine
Physiology department
Batch 8
Pulmonary function test
Presented by:
Dr Mogahed Hussein

Objectives
Explain General principles that help understanding lung V & C
Explain lung V & c to ease the concept of PFT
Explain bedside PFT
Explain how spirometry measures lung volumes and airow in
patients
Explain how we measure RV, FRC, TLC indirectly with
spirometer.

s
e
l
p
i
c
n
i
r
p
l
a
r
Gene

Control of Breathing
Higher Control
Centres
DRUG EFFECTS e.g.
OPIATES &
CAFFEINE

MEDULLARY &
CAROTID
CHEMORECEPTORS

RESPIRATORY
CENTRE (Medulla)
STRETCH &
PROPRIOCEPTORS
LUNGS & CHEST WALL

RESPIRATORY
REFLEXES

CRANIAL & SPINAL

MOTOR NEURONES

INSPIRATION

Respiratory Reflexes

Hering-Breuer reflexes
Lung inflation inhibition of breathing
Prolonged inhalation expiratory muscle contraction
Rapid deflation prolonged inspiratory response

Heads paradoxical reflex

Rapid inflation diaphragmatic contraction (sigh)

Intercostal phrenic inhibitory reflex

Chest wall distortion shallow inspiratory efforts

Irritant reflexes
Upper airway reflexes
Nasal irritation/ suction apnoea
Liquid in larynx apnoea

Chemoreceptors

Medulla Oblongata and Carotid Body

Respond to changes in pH, CO2 and O2

Resetting of carotid chemoreceptors occurs at birth in response

to oxygenation

Not essential at initiation of respiration but used for control of

breathing

Responses are weak in the immediate newborn period and in

preterm babies

Definitions

Minute volume = vol. of gas each minute

200 400 mL/kg/min

Minute volume = Tidal volume x resp. rate

PaCO2 inversely MV
PaCO2 by tidal volume or resp. rate

Dead Space = Vol. of lung not involved in ventilation (eg,

airways and ET tubes)

Compliance

Compliance is a measure of the dispensability of the lung

Compliance = Change in Volume (L)
Change in Pressure (cm H2O)

Lung disease decreases compliance

RDS (Alveolar collapse)
Fluid in insterstitium
Lung fibrosis
Pneumothorax (Lung compression)
Surfactant improves compliance

Airways Resistance

Measure of the pressure gradient needed for gas to flow

through a tube

Airway resistance = Pressure difference

(RAW)
Gas flow

Poiseuilles equation
R airway length
R 1/ radius
AW
AW

Work of Breathing

Energy required to produce change in lung volume

Increases

with decreased compliance

Increases with increased resistance

If energy required to breath exceeds capacity to supply

oxygen to provide that energy then respiratory failure
develops requiring mechanical ventilation

Pressure Volume Curves

(Lung hysteresis loops)
VOLUME
EXP

INSP

PRESSURE

Pressure Volume Curves

(Lung hysteresis loops)
VOLUME

HIGH
COMPLIANCE

LOW
COMPLIANCE

PRESSURE

d
n
a
s
e
m
u
l
o
s
V
e
i
t
g
i
c
n
a
u
L
p
a
C

Lung Volumes and Capacities

PFT tracings have:
Four Lung volumes: tidal
volume, inspiratory reserve
volume, expiratory reserve
volume, and residual
volume

Five capacities:,
inspiratory capacity,
expiratory capacity, vital
capacity, functional
residual capacity, and total
lung capacity

Addition of 2 or more volumes comprise a

capacity.

Lung Volumes

Tidal Volume (TV): volume of

air inhaled or exhaled with
each breath during quiet
breathing (6-8 ml/kg)
Inspiratory Reserve Volume
(IRV): maximum volume of air
inhaled from the endinspiratory tidal position.(19003300ml)
Expiratory Reserve Volume
(ERV): maximum volume of
air that can be exhaled from
resting end-expiratory tidal
position.( 700-1000ml).

Lung Volumes
Residual Volume (RV):
Volume

of air
remaining in lungs
after maximum
exhalation (20-25
ml/kg) (1700-2100ml)
Indirectly measured
(FRC-ERV)
It can not be
measured by
spirometer

Lung Capacities

Total Lung Capacity (TLC):

Sum of all volume compartments
or volume of air in lungs after
maximum inspiration (4-6 L)
Vital Capacity (VC): TLC minus
RV or maximum volume of air
exhaled from maximal
inspiratory level. (60-70 ml/kg)
(3100-4800ml)
Inspiratory Capacity (IC): Sum
of IRV and TV or the maximum
volume of air that can be inhaled
from the end-expiratory tidal
position. (2400-3800ml).
Expiratory Capacity (EC): TV+
ERV

Lung Capacities (cont.)

Functional Residual
Capacity (FRC):

Sum of RV and ERV or the

volume of air in the lungs at
end-expiratory tidal
position.(30-35 ml/kg)
(2300-3300ml).
Measured with multiplebreath closed-circuit helium
dilution, multiple-breath
open-circuit nitrogen
washout, or body
plethysmography.
It can not be measured by
spirometry)

VOLUMES, CAP
A
CITIES AND
THEIR CLINICA
L SIGNIFICANC
E

1)

TIDAL VOLUME (TV):

Volume of air inhaled or exhaled with each breath during

quiet breathing (6-8 ml/kg)
Compliance and muscle strength
2) VITAL CAPACITY:
Measured with VITALOGRAPH

FACTORS INFLUENCING VC

PHYSIOLOGICAL :
physical dimensions- directly proportional to height.

SEX more in males : large chest size, more muscle power. **

AGE decreases with increasing age**

Muscle strength.

POSTURE decreases in supine position by altering pulmonary

Blood volume.**

PREGNANCY- unchanged or increases by 10% ( increase in AP

diameter In pregnancy)

FACTORS DECREASING VITAL

CAPACITY
1)

Alteration in muscle power- drugs, NMJ disorders.,

cerebral tumors.

2)

Pulmonary diseases pneumonia, chronic bronchitis,

asthma, fibrosis, emphysema, pulmonary edema,.**

3)

Space occupying lesions in chest- tumours,

pleural/pericardial effusion, kyphoscoliosis**

4)

Abdominal tumours, ascites.**

5) Depression of respiration : opioids

6) Abdominal splinting abdominal binders, tight

bandages.

7)Abdominal pain decreases by 50% & 75% in lower &

upper abdominal Surgeries respectively.**

CONTINUED
3) FUNCTIONAL RESIDUAL CAPACITY (FRC):
Volume of air remaining in the lungs after normal tidal
expiration, when there is no airflow.

N- 2 -3 L OR 30-35 ml/kg.

FRC = RV + ERV
Decreases under anesthesia **

With paralysis decreases by 16%

FUNCTIONS OF FRC

Oxygen store **increase time to develop hypoxia**

Buffer for maintaining a steady arterial po2

Partial inflation helps prevent atelectasis**

Minimize the work of breathing

Minimize pulmonary vascular resistance

Minimized v/q mismatch

Keep airway resistance low

FACTORS AFFECTING FRC

FRC INCREASES WITH

Increased height
Erect position (30% more than in supine)
Decreased lung recoil (e.g. emphysema)**
FRC DECREASES WITH
Obesity **
Muscle paralysis (especially in supine)
Supine position **
Restrictive lung disease (e.g. fibrosis, Pregnancy)
Anesthesia
FRC does NOT change with age.

s
t
s
e
T
n
o
i
t
c
n
u
F
y
r
a
n
o
m
l
u
P

Pulmonary Function Tests

The term encompasses a wide variety of objective tests

to assess lung function

Provide objective and standardized measurements for

assessing the presence and severity of respiratory
dysfunction.

GOALS

To predict the presence of pulmonary dysfunction

To know the functional nature of disease (obstructive or
restrictive. )
To assess the severity of disease
To assess the progression of disease
To assess the response to treatment
To identify patients at increased risk of morbidity and
mortality, undergoing pulmonary resection.

GOALS, CONTINUED..

To wean patient from ventilator in ICU.

Medicolegal- to assess lung impairment as a result of

occupational hazard.

Epidemiological surveys- to assess the hazards to

document incidence of disease

To identify patients at perioperative risk of pulmonary

complications

BED SIDE
PFT

BED SIDE PFT

1)Sabrasez breath holding test:
Ask the patient to take a full but not too deep breath & hold it as long as possible.
>25 SEC.-NORMAL Cardiopulmonary Reserve (CPR) **
15-25 SEC- LIMITED CPR
<15 SEC- VERY POOR CPR (Contraindication for elective surgery)
25- 30 SEC - 3500 ml VC
20 25 SEC - 3000 ml VC
15 - 20 SEC - 2500 ml VC
10 - 15 SEC - 2000 ml VC
5 - 10 SEC - 1500 ml VC

BED SIDE PFT

2) Single breath count:
After deep breath, hold it and start counting till the next
breath.

N- 30-40 COUNT
Indicates vital capacity

BED SIDE PFT

3) SCHNEIDERS MATCH BLOWING TEST: MEASURES Maximum
Breathing Capacity.**
Ask to blow a match stick from a distance of 15 cm with:

Mouth wide open

Chin rested/supported

No purse lipping

No head movement

No air movement in the room

Mouth and match at the same level

BED SIDE PFT

Can not blow out a match

MBC < 60 L/min
FEV1

< 1.6L**

Able to blow out a match

MBC > 60 L/min
FEV1

> 1.6L

MODIFIED MATCH TEST:

DISTANCE

MBC

>150 L/MIN.

>60 L/MIN.

> 40 L/MIN.

BED SIDE TEST

4) COUGH TEST: DEEP BREATH COUGH
ABILITY TO COUGH
STRENGTH
EFFECTIVENESS
INADEQUATE COUGH IF:
FVC<20 ML/K
FEV1 < 15 ML/KG
PEFR < 200 L/MIN.
##VC ~ 3 TIMES TV FOR EFFECTIVE COUGH.##

BED SIDE TEST

5) FORCED EXPIRATORY TIME:
After deep breath, exhale maximally and forcefully & keep
stethoscope over trachea & listen.
N FET 3-5 SECS.
OBS.LUNG DIS. - > 6 SEC
RES. LUNG DIS.- < 3 SEC

BED SIDE PFT

6) WRIGHT PEAK FLOW METER:
Measures PEFR (Peak Expiratory Flow Rate)**
N MALES- 450-700 L/MIN.
FEMALES- 350-500 L/MIN.
<200 L/ MIN. INADEQUATE COUGH EFFICIENCY.

MEASUREMENT OF TV & MV
7)Wright respirometer :
Measures TV, MV..
Simple and rapid

Instrument- compact, light and portable.

Disadvantage: It under- reads at low flow rates and over- reads

at high flow rates.

Can be connected to endotracheal tube or face mask

Prior explanation to patients needed.

Ideally done in sitting position.

MV- instrument record for 1 min. And read directly

TV-calculated and dividing MV by counting Respiratory Rate.

USES:
1)BED SIDE PFT
2) ICU WEANIG PTS. FROM Ventilation.

BED SIDE PFT

8) MICROSPIROMETERS MEASURE VC.

9) BED SIDE PULSE OXIMETRY

10) ABG.**

CATEGORIZATION OF PFT

1)

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:

2) GAS- EXCHANGE TESTS:

3) CARDIOPULMONARY INTERACTION:

F
O
S
N
O
TI
C
N
U
F
Y
R
O
T
A
IL
T
N
L:
E
L
V
A
L
W
A
C
T
I
S
N
E
A
H
H
C
/
MEC
LUNG

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:
A)

STATIC LUNG VOLUMES & CAPACITIES

VC, IC, IRV, ERV, RV, FRC.

B)

DYNAMIC LUNG VOLUMES

FVC, FEV1, FEF 25-75%, PEFR, MVV, RESP. MUSCLE

STRENGTH
C)

VENTILATION TESTS

TV, MV, RR.

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:

S
E
M
U
L
O
V
G
N
U
L
c
i
m
Dy n a
S
E
I
T
I
C
A
P
A
AND C

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:

SPIROM
ET ER

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:

SPIROMETRY : CORNERSTONE OF ALL PFTs.

John hutchinson invented spirometer.

Spirometer is a medical test that measures the

volume of air an individual inhales or exhales as a
function of time.

Measures VC, FVC, FEV1, PEFR.

CANT MEASURE FRC, RV, TLC. **

PREREQUISITIES

Prior explanation to the patient

Not to smoke /inhale bronchodilators 6 hrs prior or oral
bronchodilators 12hrs prior.
Remove any tight clothing's/ waist belt
Pt. Seated comfortably
If obese, child < 12 yrs- standing

PREREQUISITES

Nose clip to close nostrils.

Exp. Effort should last 4 secs.

Should not be interfered by coughing, glottis closure,

mechanical obstruction.

3 acceptable tracings taken & largest value is used.

FORCED VITAL CAPACITY

(FVC)

Max vol. Of air which can be expired out as forcefully and

rapidly as possible, following a maximal inspiration to TLC.

Exhaled volume is recorded with respect to time.

Indirectly reflects flow resistance property of airways.

Normal healthy subjects have VC = FVC.

Prior instruction to patients, practice attempts as it

needs patient cooperation and effect.

Exhalation should take at least 4 sec and should not be

interrupted by cough, glottis closure or mechanical
obstruction.

FORCED VITAL CAPACITY IN 1

SEC. (FEV1)

Forced expired vol. In 1 sec during FVC maneuver.

Expressed as an absolute value or % of FVC .

N- FEV1 (1 SEC)- 75-85% OF FVC

FEV2 (2 SEC)- 94% OF FVC

FEV3 (3 SEC)- 97% OF FVC

CONTINUED
CLINICAL RANGE (FEV1)

PATIENT GROUP

3 - 4.5 L

NORMAL ADULT

1.5 2.5 L

MILD
MOD.OBSTRUCTION

<1 L

HANDICAPPED

0.8 L

DISABILITY

SEVERE EMPHYSEMA

0.5 L

CONTINUED
FEV1 Decreased in both obstructive & restrictive lung
disorders.
FEV1/FVC Reduced in obstructive disorders.
NORMAL VALUE IS 75 85 % (FEV1/FVC)
< 70% OF PREDICTED VALUE MILD OBST.
< 60% OF PREDICTED VALUE MODERATE OBST.
< 50% OF PREDICTED VALUE SEVERE OBST.

Spirometry Interpretation:
Obstructive vs. Restrictive Defect

Obstructive Disorders

Characterized by a
limitation of expiratory
airflow so that airways
cannot empty.

Examples:
Asthma

Emphysema

Restrictive Disorders

Characterized by reduced lung

volumes/decreased lung compliance

Examples:
Interstitial Fibrosis

Scoliosis

Obesity

Lung Resection

Neuromuscular diseases

Cystic Fibrosis

Cystic Fibrosis

CONTINUED
DISEASE
STATES

FVC

FEV1

FEV1/FVC

1) OBSTRUCTIV
E

normal or

2) STIFF LUNGS

slightly

NORMAL

3 ) RESP.
MUSCLE
WEAKNESS

NORMAL

Spirometry Interpretation: What do the

numbers mean?
FVC
Interpretation of %
predicted:

FEV1
Interpretation of %
predicted:

80-120% Normal

>75% Normal

70-79% Mild reduction

60%-75% Mild obstruction

50%-69% Moderate
reduction

50-59% Moderate
obstruction

<50% Severe reduction

<49% Severe obstruction

Spirometry Interpretation: What do the

numbers mean?
FEF 25-75% Interpretation of
% predicted:
>79% Normal
60-79% Mild

FEV1/FVC Interpretation of
absolute value:
80 or higher
Normal

obstruction
79

40-59% Moderate

obstruction
<40%

Severe
obstruction

or lower
Abnormal

Spirometry Interpretation:
Obstructive vs. Restrictive Defect
Obstructive
FVC

Disorders

normal or

FEV1

TLC

nl or

FVC

**

FEF

Disorders

FEV1

FEF25-75%
FEV1/FVC

Restrictive

slight

25-75% nl to

FEV1/FVC nl to

TLC

Obstructive vs. Restrictive

(Hyatt
,
2003)

Volumetime curves obtained during forced

expiration using a wedge-bellows spirometer.
(a) The subject has taken a full breath in and exhaled forcibly and fully.
Maximal ow decelerates as forced expiration proceeds, because the
airways decrease in size as the lung volume diminishes**.
Exhalation is terminated when the expired ow rate falls to <0.25
litres/sec (as here) or at 14 sec.
(b) Obstructive and restrictive patterns. In obstruction, FEV1/FVC is low;
in restrictive disorders it is normal or high.
(c) Straight line traces (a) in central airways obstruction, ow is constant
through the rst half of expiration; (b) Tracheo-bronchial collapse occurs
in severe emphysema and tracheomalacia the rst 200 ml is exhaled
rapidly after which the compressed airway behaves like a xed central
obstruction.
(d) Response of FEV1 to treatment. A patient with moderate asthma
tested before and after salbutamol and after a course of prednisolone.
FEV1 improves more than FVC

PEAK EXPIRATORY FLOW RATE

(PEFR)
It is the max. Flow rate during FVC maneuver in the initial 0.1
sec.
-PEFR DETERMINED BY :
1)Function of caliber of airway
2)Expiratory
3)Pts

muscle strength

coordination & effort

- Estimated by Average flow during the liter of gas expired after

initial 200 ml during FVC maneuver.
-.

FORCED MID-EXPIRATORY FLOW

RATE (FEF25%-75%):

Maximum Mid expiratory Flow rate..Max. Flow rate

during the mid-expiratory part of FVC maneuver.

FEF25-75% decreased by :

1)

marked reduction in exp. Effort

2)

submaximal inspiration maneuver FVC FEF25-75%

It may decrease with truly max. Effort as compared to

slightly submaximal effort .
N value 4.5-5 L/sec. Or 300 L/min.

CLINICAL SIGNIFICANCE:

SENSITIVE & IST INDICATOR OF OBSTRUCTION OF

SMALL DISTAL AIRWAYS

MAXIMUM BREATHING CAPACITY: (MBC/MVV)

MAX. VOLUNTARY VENTILATION

Largest volume that can be breathed per minute by

voluntary effort , as hard & as fast as possible.

N 150-175 l/min.

Estimate of max. Ventilation available to meet increased

physiological demand.

Measured for 12 secs extrapolated for 1 min.

MVV = FEV1 X 35

CONTINUED.
-

MBC/MVV altered by- airway resistance

Elastic property

Muscle strength

Learning and Coordination

Motivation

RESPIRATORY MUSCLE STRENGTH

Evaluated by measuring max inspiratory and expiratory
Efforts.
Pressures are generated against occluded airway .
MAX STATIC INSP. PRESSURE: (PIMAX)

Measured when inspiratory muscles are at their optimal length i.e. at RV

PI MAX = -125 CM H2O

CLINICAL SIGNIFICANCE:

IF PI MAX< 25 CM H2O Inability to take deep breath.

CONTINUED.

MAX. STATIC EXPIRATORY PRESSURE (PEMAX):

Measured after full inspiration to TLC

N VALUE OF PEMAX IS =200 CM H20

PEMAX < +40 CM H20 Impaired cough ability

Particularly useful in pts with NM Disorders during

weaning

Spirometry Pre and Post

Bronchodilator

Obtain a flow-volume loop.

Administer a bronchodilator.

Obtain the flow-volume loop again a minimum of 15

minutes after administration of the bronchodilator.

Calculate percent change (FEV1 most commonly used--so % change FEV 1= [(FEV1 Post-FEV1 Pre)/FEV1 Pre]
X 100).

The response of FEV1 and other measures of airflow

obstruction to bronchodilators is measured routinely,
without any consensus as to how this should be
performed or interpreted.

It is mainly used to identify untreated asthma, when

dramatic improvements of 0.5 litres or more may be
seen after only 200 mcg of inhaled salbutamol..

Disappointingly there is no test which identies asthma

in the presence of COPD.

An improvement of 15% or 0.4 liters (the greater) after

2.5 mg nebulized salbutamol points towards some
potential for reversibility, but current guidelines
emphasize the need for several days of therapy rather
than a single laboratory test to assess this potential.

In COPD, post-bronchodilator FEV1 and VC vary less

than pre-bronchodilator readings and should ideally be
used to measure changes of lung function over time in
longitudinal studies of obstructive disorders.

Bronchial challenges with histamine, methacholine, cold

air or intensive exercise are used to conrm asthma in
individuals with normal resting spirometric tests.

Asthmatic subjects react to pharmacological

bronchoconstrictors with a 20% fall of FEV1 at a much
lower dose than non-reactive individuals

MECHANICAL VENTILATORY FUNCTIONS OF

LUNG / CHEST WALL:

MEASUREMENTS OF
VOLUMES

TLC, RV, FRC MEASURED USING

Nitrogen

washout method

Inert

gas (helium) dilution method

Total

body plethysmography

1) HELIUM DILUTION METHOD:

Patient breathes in and out of a spirometer filled with 10%
helium and 90% o2, till conc. In spirometer and lung
becomes same (equilibrium).
As no helium is lost; (as it is insoluble in blood)
C1 X V1 = C2 ( V1 + V2)
V2 = V1 ( C1 C2)
C2
V1= VOL. OF SPIROMETER
V2= FRC
C1= Conc.of He in the spirometer before equilibrium
C2 = Conc, of He in the spirometer after equilibrium

2) TOTAL BODY
PLETHYSMOGRAPHY:
The subject sits in a closed booth (body box,
plethysmograph) of known volume and breathes in and out
against a closed tube for a few seconds.
According to Boyles Law the ratio of the pressures in the
mouth and around the subject is determined by the ratio of
The volumes of the lungs and the box.
BOYLES LAW:
P and V are CONSTANT at CONSTANT temp.

For Box p1v1 = p2 (v1- v)

For Subject p3 x v2 =p4 (v2 - v)
P1- initial box pr. P2- final box pr.
V1- initial box vol. v- change in box vol.
P3- initial mouth pr., p4- final mouth pr.
V2- FRC

CONTINUED
DIFFERENCE BETWEEN THE TWO METHODS:

In healthy people there is very little difference.

Gas dilution technique measures only the

communicating gas volume.

Thus, gas trapped behind closed airways, gas in

pneumothorax are not measured by gas dilution
technique, but measured by body plethysmograph

CONTINUED
3) N2 WASH OUT METHOD:

Following a maximal expiration (RV) or normal expiration

(FRC), Pt. inspires 100% O2 and then expires it into
spirometer ( free of N2) over next few minutes
(usually 6-7 min.), till all the N2 is washed out of the
lungs.

N2 conc. of spirometer is calculated followed by total

vol.of AIR exhaled. As air has 80% N2 so actual
FRC/RV is calculated.

:
S
T
S
E
T
E
G
N
A
H
C
X
E
S
GA

2) GAS- EXCHANGE TESTS:

A) Alveolar-arterial po2 gradient
B) Diffusion capacity
C) Gas distribution test: Helium dilution method.
D) ventilation perfusion tests
1-ABG
2-single breath CO2 elimination test
3-Shunt equation

TESTS FOR GAS EXCHANGE

FUNCTION
1)

ALVEOLAR-ARTERIAL O2 TENSION GRADIENT:

Sensitive indicator of detecting regional V/Q inequality

Normal value in young adult at room air = 8 mmHg to up to

25 mmHg in 8th decade (d/t decrease in PaO2)

Abnormally high values at room air is seen in asymptomatic

smokers & chronic Bronchitis
PAO2 = PIO2 PaCo2
R

CONTINUED..
2) DYSPNEA DIFFENRENTIATION INDEX (DDI):
-

To d/f dyspnea due to resp/ cardiac ds

DDI = PEFR x PaCO2
1000

DDI- Lower in resp. pathology

CONTINUED
3) DIFFUSING CAPACITY OF LUNG:
Defined as the rate at which gas enters into blood.
divided by its driving pressure.

CO taken up is determined by infrared analysis:

DlCO = CO ml/min/mmhg
PACO PcCO
N range 20- 30 ml/min./mmhg.

DLO2 = DLCO x 1.23

DRIVING PR: gradient b/w alveoli & end capillary tensions.

Ficks law of diffusion : Vgas = A x D x (P1-P2)
T
D= diffusion coeff= solubility
MW

CONTINUED.

DL IS MEASURED BY USING CO, cause:

A)

High affinity for Hb which is approx. 200 times that of

O2 , so does not rapidly build up in plasma

B)

Under N condition it has low bld conc 0, Therefore,

pulm conc.0

SINGLE BREATH TEST USING

CO

The patient inhales from full expiration from a reservoir

containing a trace of CO (0.03%), about 10% helium (or
other non-absorbed gas) with 1620% oxygen and hold
the breath for 10 secs

Helium dilution is used to measure the accessible

volume of alveolar gas (VA).

Carbon monoxide is both diluted and absorbed, thus:

inspired[CO]/expired[CO] is greater than inspired[He]/
expired[He]; i.e. the ratio of CO uptake to helium dilution
(CO ratio) >1.
It is assumed that CO is absorbed exponentially during the
period of breath-holding; because Pco is zero in the
pulmonary blood and the pressure gradient is the alveolar
pressure of the gas

Therefore
DLco = VA x (CO ratio) x (1/breath-holding time) x (1/dry
barometric pressure).
The units are CO uptake per unit time per pressure unit
difference from alveolar gas to blood.
DLco/VA is calculated by dividing DLco by VA measured at
body temperature and pressure, saturated with water
vapour.

The amount of CO extracted depends on:

The diffusing capacity of the alveolar membrane,
comprising: The area of the gas exchanging surface of the
lung.

The
The

thickness of the alveolar capillary barrier.

pulmonary capillary blood volume (the volume of

haemoglobin in contact with the inhaled gas).

DLco depends mainly on alveolar function except:

When the airways are abnormal and a deep breath is not evenly
distributed to all parts of the lung.
When

the concentration of hemoglobin in the red cells is not normal.

There are two ways of reporting diffusing capacity. :

DLco is the rate of uptake of CO per unit of alveolar Pco in the whole
lung
In

some situations it can be helpful to divide this by the lung volume;

this yields an index known as diffusion or transfer coefcient DL/VA.

In practice both are useful in separate situations.

The calculation of DLco assumes that regional variations of
ventilation, perfusion and diffusion are averaged out.
In patients with respiratory failure severe ventilation perfusion
mismatching can result in marked abnormalities of CO2 and O2
exchange when DLco is normal.
Conversely, a low DLco is compatible with a normal resting
arterial Po2. Oxygen exchange in exercise is invariably abnormal
when DLco is low.

Interpretation of DLco and DL/VA are useful clinically in a

number of situations.
When VC, FEV1, FVC and [Hb] are all normal, a low DLco
strongly suggests disease involving the alveoli.
In airow obstruction a low DLco and DLco/VA suggest
alveolar destruction (emphysema).
In contrast, they are sometimes abnormally high in asthma.

In restrictive pleural and chest wall disease, a high

DLco/ VA suggests that there is no underlying lung disease.
When there are widespread radiological lung shadows,
such as in sarcoidosis or some occupational lung diseases,
DLco reects lung impairment and disability but is not
correlated directly with the extent of the abnormality on the
plain CXR.
Polycythaemia, pulmonary plethora such as in heat failure
or left-to-right shunting and pulmonary haemorrhage cause
an increase in DLco because of increases in the volume of
haemoglobin in contact with the inspired air.

DLCO decreases in Emphysema, lung resection, pul. Embolism, anemia

Pulmonary fibrosis, sarcoidosis- increased thickness

DLCO increases in conditions which increase pulmonary,

blood flow:
Supine position..ExerciseObesity

L-R shunt.Polycythemia.pulmonary
plethora.pulmonary hemorrhage

CATEGORIZATION OF PFT

R
O
F
S
Y
T
R
S
A
E
N
T
)
O
3
M
L
U
L
P
S
O
N
I
D
O
I
R
T
A
C
C
A
R
E
T
IN
www.anaesthesia.co.in

CATEGORIZATION OF PFT
3) CARDIOPULMONARY INTERACTION:
Reflects gas exchange, ventilation, tissue O2, CO.
A) Qualitative tests:
- History , examination
- ABG
- Stair climbing test
B) Quantitative tests
- 6 min. Walk test (gold standard)

www.anaesthesia.co.in

CONTINUED.
1) STAIR CLIMBING TEST:
If able to climb 3 flights of stairs without stopping/dypnoea
at his/her own pace- morbidity & mortality
If not able to climb 2 flights high risk

2) 6 MINUTE WALK TEST:

-Gold

standard

-C.P. reserve

is measured by estimating max. O2 uptake

during exercise
-Modified

if pt. cant walk bicycle/ arm exercises

If pt. is able to walk for >2000 feet during 6 min pd,

VO2 max > 15 ml/kg/min

If 1080 feet in 1 min : VO2 of 12ml/kg/min

Simultaneously oximetry is done & if Spo2 falls >4%high risk

Applied physiology
A 34-year-old woman with diabetes presents to the
emergency department with complaints of fever, chills,
back pain, dizziness, and shortness of breath. She reports
a new-onset nonproductive cough and denies having chest
pain. She reports no sick contacts. On examination, she is
ill-appearing, febrile, hypotensive, and tachycardic. She has
marked right costovertebral (flank) tenderness.
Her lung examination demonstrates course rales and
rhonchi throughout both lung fields. Her heart rate is
tachycardic, but with a regular rhythm.

Applied physiology
Her oxygen saturation on room air is very low at 80%
(normal > 94%). Urinalysis reveals numerous bacteria and
leukocytes, consistent with a urinary tract infection. She is
diagnosed with pyelonephritis and septic shock and has
evidence of adult respiratory distress syndrome (ARDS)
with bilateral pulmonary infiltrates on chest x-ray. The
emergency room physician explains to the patient that
pulmonary injury has led to leaky pulmonary capillaries.

Applied physiology
How does pulmonary capillary leakage
cause hypoxia?
After a patient takes a normal breath and
exhales, what lung volume remains?
How do obstructive lung diseases such as
asthma affect forced expiratory volume?

Applied physiology
Summary: A 34-year-old diabetic woman has pyelonephritis, septic
shock, and ARDS.
Pulmonary capillary leakage and hypoxia: Accumulation of excess
fluid outside the capillaries leads to altered local ventilation and
perfusion and makes gas exchange inefficient.
Lung volume remaining after normal breath: Functional residual
capacity (FRC; cannot be measured with spirometry alone).
Forced expiratory volume with obstructive airway disease:
Decreased.

COMPREHENSION
QUESTIONS

[1] In a 58-year-old woman with difficulty breathing, the TLC and FRC are
lower than normal and FEV1/FVC is slightly higher than normal. These
findings are most consistent with which of the following?
A.Decreased

pulmonary blood flow

B.Decreased

strength of the chest wall muscles

C.Increased

airway resistance

D.Increased

chest wall elastic recoil

E.Increased

lung elastic recoil

COMPREHENSION
QUESTIONS
[2] A patient has reduced TLC and increased RV. FRC is
normal. These findings are most consistent with which of
the following?
A. Decreased pulmonary blood flow
B. Decreased strength of the muscles of respiration
C. Increased airway resistance
D. Increased chest wall elastic recoil
E. Increased lung elastic recoil

COMPREHENSION
QUESTIONS

[3] A chest x-ray of a patient with left-sided heart failure

indicates pulmonary edema. Additional examination
probably would reveal which of the following?
A.Decreased pulmonary artery pressure
B. Decreased pulmonary lymph flow
C. Increased pulmonary venous pressure
D. Normal arterial oxygen partial pressure
E. Normal vital capacity

Answers

[1] E. A lung with increased elastic recoil (decreased

compliance) will be harder to fill on inspiration and will
tend to pull the chest wall inward on relaxation of the
muscles of breathing. Thus, both TLC and FRC will be
decreased. Because airway radius is normal or even
increased, FEV1 normalized to FVC will be normal or
increased even though FVC will be reduced. Decreased
muscle strength could cause a decrease in TLC, but it
would not alter FRC.

[2] B. If the muscles of inspiration are weak, lungs cannot

be inflated as well, thus reducing the inspiratory reserve
volume and TLC. If the muscles of expiration are weak, not
as much air can be forced from the lungs and expiratory
reserve volume will be decreased, thus increasing RV.
Increases in elastic recoil of either the chest wall or the
lungs and increases in airway resistance will alter TLC
and/or FRC.

{3} C. As a result of the decrease in myocardial contractility,

end diastolic pressure in the left ventricle increases, leading
to an increase in the pulmonary venous and pulmonary
capillary pressures. The increased pulmonary capillary
hydrostatic pressure leads to increased pulmonary capillary
filtration, and when filtration exceeds lymph flow, pulmonary
edema develops. Pulmonary artery pressure is likely to be
increased in this condition. The edema interferes with gas
exchange and with lung inflation; thus, arterial oxygen
partial pressure and vital capacity will be decreased.

References
LANGE

CASE FILES: PHYSIOLOGY

Lippincott Medical-Physiology-Principles-forClinical-Medicine-4th-Ed-Gnv64
Oxford Desk Reference - Respiratory
Medicine
Powell FL. Mechanics of breathing. In:
Johnson LR, ed. Essential Medical
Physiology. 3rd ed. San Diego, CA: Elsevier
Academic Press; 2003:277-288.

U
O
Y
K
N
A
H
T