Pulmonary

Function Test

JOHN NICOLE JARA, CSU INTERN

 Pulmonary function tests (PFTs) are a group of tests
that measure how well your lungs work. This
includes how well you’re able to breathe and how
effective your lungs are able to bring oxygen to the
rest of your body.

Is a complete evaluation of the respiratory

system including patient history, physical
examinations, chest x-rays, arterial blood gas
analysis and test of pulmonary function.
 Assesses the functional status of the lungs as it relates to

1.How much air volume can be moved in and out of the lung.
2.How fast the air in the lungs can be moved in and out.
3. How stiff are the lungs and the chest wall.
4.How the lungs responds to certain modalities.
5. Diffusion characteristics of the membrane through which the gas
moves.
 Screening for the presence of Restrictive or Obstructive
Lung Diseases
 Evaluation of patient prior to surgery(Pulmonary
Clearance)
 Determination of severity of pulmonary
diseases(Restrictive or Obstructive)
PFTs will measure:

 Dynamic flow rates of gases through airways,

 Lung volumes & capacities
 Ability of lungs to diffuse gases
 Indications
 To identify and quantify changes in pulmonary function
 To evaluate need and quantify therapeutic
effectiveness
 To perform epidemiologic surveillance for pulmonary
disease
 To assess patients for risk of postoperative pulmonary
complications
 To determine pulmonary disability
 Contraindications
 Hemoptysis
 Pneumothorax
 Myocardial infarction
 Pulmonary embolism
 Patients with acute chest/abdominal pain
 Patients with nausea and who are vomiting
 Patients with recent eye surgery
 Patients wit dementia/confusion
 Hazards/Complications
 Pneumothorax
 Paroxysmal coughing
 Increased ICP
 Contraction of nosocomial infections
 Syncope, dizziness
 Chest pain
 Bronchospasm
Lung
volumes
&
Capacities
 Lung Volumes
Tidal Volume (VT) - Volume of air inhaled or 10% of TLC; 500ml
exhaled during each normal breath

Inspiratory reserve volume (IRV) - Maximal 50% of TLC; 3100ml

volume of air that can be inhaled over and
above the inspired tidal volume

Expiratory reserve volume (ERV) - Maximal 20% of TLC; 1200ml

volume of air that can be exhaled after
exhaling a normal tidal breath

Residual volume (RV) - Volume of air remaining 20% of TLC; 1200ml

in the lungs after a maximal exhalation
 Lung Capacities
Inspiratory Capacity (IC) -Maximal - IC = VT + IRV
volume of air that can be inhaled from the – 60% of TLC; 3600ml
resting end-expiratory level

Vital Capacity (VC) -Maximal volume of - VC = IRV` + VT + ERV

air that can be exhaled after a maximal - 80% of TLC; 4800ml
inhalation

Functional Residual Capacity (FRC) - - FRC = ERV +RV

Volume of air present in the lung at end- - 40% of TLC; 2400ml
expiration during tidal breathing

Total Lung Capacity (TLC) - Maximal - TLC = VT + IRV + ERV + RV

volume of air in the lungs at the end of a - 6000 ml
maximal inhalation
SPIROMETRY
 SPIROMETRY
 the most common PFT

 a test that measures lung function, specifically the

measurement of the amount (volume)and/or speed
(flow) of air that can be inhaled and exhaled by an
individual

 Assesses the ability of lungs to move large volumes of air

quickly through the airways to identify airway obstruction
Classification of Spirometers
PRIMARY VOLUME MEASURING SPIROMETERS

A. Volume collecting or volume displacement

Water-sealed spirometer
Dry-sealed spirometer
Bellows spirometers

B. Flow-Through device
Rotor Spirometer
c. PRIMARY FLOW MEASURING SPIROMETERS

Differential pressure pneumotachometers

Thermal anemometers
Ultrasonic sensor spirometer
Dedicated peak flow meter
 SPIROMETRY

Can measure: Cannot measure:

 Forced Vital Capacity  Residual Volume
and its derivatives  Functional Residual
 Peak expiratory flow Capacity
rate  Total Lung Capacity
 Maximum voluntary
ventilation
 Pre- and Post-
bronchodilator studies
 SPIROMETRY

INDICATIONS
 Detect the presence or absence of lung dysfunction suggested by history or
physical signs and symptoms or the presence of other abnormal diagnostic tests
 Quantify the severity of known lung disease
 Assess the change in lung function over time or after administration of or change in
therapy
 Assess the potential effects or response to environmental or occupational exposure
 Assess the risk for surgical procedures known to affect lung function
 Assess impairment or disability
CONTRAINDICATIONS
 Hemoptysis of unknown origin
 Pneumothorax
 Unstable cardiovascular status or recent myocardial infarction or
pulmonary embolus
 Thoracic, abdominal, or cerebral aneurysms
 Recent eye surgery
 Presence of an acute disease process that might interfere with test
performance (e.g., nausea, vomiting)
 Recent surgery of thorax or abdomen
HAZARDS AND COMPLICATIONS

 Pneumothorax
 Paroxysmal coughing
 Increased intracranial pressure
 Contraction of nosocomial infections
 Syncope, dizziness, lightheadedness
 O2 desaturation resulting from interruption of O2 therapy
 Chest pain
 Bronchospasm
 PATIENT PREPARATION

 Patients must be well-rested. No strenuous activities on the day of

the procedure.
 Eat a light meal.
 No drinking of coffee, tea, softdrinks, and alcohol
 No smoking
 Wear loose clothing.
 Withhold medications
 Short-acting bronchodilators – withhold 4-6 hours prior the test
 Long-acting bronchodilators - withhold 12-24 hours prior the test
1. Calibrate the machine.
2. Aerate the sensor (is needed)
3. Verify order.
4. Explain the test. RESPIRATORY THERAPIST
 what the test measures PREPARATION
 what they will need to do
 how many times they will need to do it
5. Prepare the subject.
 Measure height and weight of subject without shoes.
 Arterial blood gas (If indicated)
 Ask about smoking history (compute for pack years)

Pack Years = No. of years the patient has smoked x No. of packs per day

Pack Years = {(Current age – Age started smoking) – Years since stopped smoking x
packs per day.}

6. Give clear, simple instructions.

7. Demonstrate correct posture and the amount of force needed when
exhaling.
 Standing is preferable, particularly for obese, pregnant, and
children
 Subjects should be tested in the same position used in the first
time.
 If subject is sitting, legs should be uncrossed and both feet on the
floor. Should lean forward.
 Elevate chin and extend neck slightly.
 PERFORM FVC MANEUVER

MEET ACCEPTABILITY CRITERIA

ACCEPTABILITY MANEUVERS > OR = 3

MEET REPRODUCIBILITY CRITERIA

BEST TEST CURVE

DETERMINE LARGEST FVC (LARGEST SUM FEV1 + FVC)
& LARGEST FEV1

INTERPRET
MANEUVERS:

1. Forced Vital Capacity

2. Slow Vital Capacity
3. Maximum Voluntary Ventilation
 1. FORCED VITAL CAPACITY (FVC)
 total volume of gas that can be
exhaled as forcefully and rapidly SIGNIFICANCE:
as possible after a maximal
inspiration
• FVC = VC in healthy individuals
 is an effort-dependent maneuver
that requires careful patient • Decreased FVC = obstructive &
instruction, understanding, restrictive diseases
coordination, and cooperation.
 most commonly performed test
of pulmonary mechanics
 can to measure a number of
pulmonary function values from a
single FVC maneuver.
FVC can measure a number of pulmonary function values from a single FVC
maneuver:

 Forced expiratory volume timed (FEVT)

 Forced expiratory volume in 1 second/forced vital capacity ratio
(FEV1%)
 Forced expiratory flow between 200 and 200 Ml of FVC (FEF200-1200)
 Forced expiratory flow at 25% to 75% (FEF25%-75%)
 Peak expiratory flow rate (PEFR)
Forced Expiratory Volume Timed (FEVT)

 Maximal volume of gas that can be exhaled within a specific time

period
 FEV0.5 = 60%
 FEV1.0 = 83%
 FEV2.0 = 94%
 FEV3.0 = 97%.; usually fairly close to FVC
 FEV6.0 = can substitute FVC in patients who cannot exhale
completely
= primarily used to ensure expiratory efforts meet or exceed 6
seconds.
SIGNIFICANCE:
• FEVT decreases with age
• Decreased FEVT = obstructive & restrictive diseases
FEV1

 Most widely used spirometric parameter, particularly of assessment

of airway obstruction
 Used in conjunction with FVC for:
 Simple screening
 Response to bronchodilator therapy and bronchoprovocation
 Detection of exercise-induced bronchospasm
 May be reduced in obstructive/restrictive patterns and poor patient
effort
 FEV1/FVC ratio or FEV1%
 Compares the amount of air exhaled in 1 second with
the total amount exhaled during an FVC maneuver.
 Provides the percentage of the patient’s total volume
of air forcefully exhaled (FVC) in 1 second

 (largest FEV1/ largest FVC) x 100

A decreased FEV!% is the hallmark of
obstructive disease.
Collectively, FVC, FEV1, and FEV1% are most commonly
used to:
1. Determine the severity of a patient’s obstructive disease
2. Distinguish between obstructive and restrictive lung
disorder

 Obstructive = FEV1 and FEV1% are both decreased. FVC

is often normal.

 Restrictive = FVC and FEV1 are decreased and the FEV1%

is normal or increased.
Forced expiratory flow between 200 and 200 Ml
of FVC (FEF200-1200)
 average flow rate that occurs between 200 and 1200 mL of the FVC
 Provides a good assessment of the large upper airways.
 effort-dependent
 Good test to determine the patient’s response to bronchodilator therapy
 Normal FEF200-1200 (Females) = 5.5 L/sec (330L/min)
 Normal FEF200-1200 (Males) = 8 L/sec (480 L/min)

SIGNIFICANCE:

• FEF200-1200 decreases with age

• decreased FEF200-1200 = obstructive

 Forced expiratory flow at 25% to 75%
(FEF25%-75%)

 Aka Maximal Mid-expiratory flowrate

 Average flow rate generated by the patient during the middle 50% of an FVC
measurement
 used to evaluate the status of medium-to-small airways in obstructive lung
disorders
 Effort – independent
 often used to further confirm or rule out the presence of an obstructive
pulmonary disease in the patient with a borderline FEV1% value

SIGNIFICANCE:

• decreased FEF25%-75% = obstructive & restrictive

 Peak expiratory flow rate (PEFR)
 Maximal flow rate achieved in an FVC maneuver
 Provides a good assessment of the large upper
airways.
 Effort dependent
 Takes place immediately after the start of the exhalation
 can also easily be measured at the patient’s bedside
with a hand-held peak flowmeter
SIGNIFICANCE:

• decreased PEFR = obstructive

2. Maximum Voluntary Ventilation (MVV)

 effort-dependent test for which the patient is asked to

breathe as deeply and as rapidly as possible for at least 12
seconds
 a test that reflects patient cooperation and effort, the ability
of the diaphragm and thoracic muscles to expand the thorax
and lungs, and airway patency
 Patient should be seated
SIGNIFICANCE:
 Normal values: 170 L/minute
• Obstructive = decreased
 may be calculated: (40 x FEV1) • Restrictive = decreased or normal
Flow-Volume Loop

 Graphic illustration of both FVC and FEV1

maneuvers
 The shape of the curves are extremely
diagnostic
 By examining the information and shape of
the loop, it helps clinicians further understand
the way air is moving into and out of the
lungs and help identify specific diseases that
can otherwise be very hard to diagnose.
NORMAL MILD SEVERE
RESTRICTION
OBSTRUCTION OBSTRUCTION
 ACCEPTABILITY CRITERIA
*Acceptable = free from error
GOOD START = no hesitations, quick, and forceful
GOOD END = TE of atleast 6 seconds and has a
plateau phasae

MUST HAVE NO:

1. Hesitations/ false starts – subject did not
exhale as forcefully as possible at the start
- How to check extrapolated volume must be
not more than 5% or 150 mL of the FVC

Extrapolated Volume = volume exhaled by the

patient before the timing of the maneuver has
started (zero time)
- parameter used to gauge if the subject
maximally expired at the start
2. Cough 3. Variable effort

4. Poor initial blast 5. Early termination

6. Glottis Closure 7. Leaks

8. Extra breaths 9. partially blocked mouthpiece

 CRITERIA FOR REPRODUCIBILITY
The 2 highest values for FVC and FEV1 taken from acceptable
FVC maneuvers must show minimal variability.

 The 2 largest FVC must be within 0.150L of each other

 The 2 largest FEV1 must be within 0.150L of each other
Identifying the BEST TEST/BEST
CURVE
1. Find the largest FEV1 and FVC of the same curve.
2. The average of FVC a nd FEV1 even if they do not come from the
same curve.
3. The maneuver with the largest sum of FVC and FEV1.
Reference ranges for all spirometry parameters based on
the subject’s height, gender, age, and race.

REPORTS:
1. Actual = what subject actually performed
2. Predicted = What subject should perform based on the
age, height, sex, weight, and race.
3. % Predicted = comparison of the actual value to the
predict
= (actual/predicted) x 100
STEPS IN
INTERPRETATION
NORMAL VALUES

 FVC = 80
 FEV1 = 80
 FEV1/FVC = 70
 TLC = 80 – 120
 RV = 63 – 135
 SRAW = < 120
 DLCO = > 80
STEP 1
 Check FEV1/FVC ratio ( pre-measured
or pre Rx best values)
 If ≥ 70, no obstruction
 If < 70, there’s obstruction. Look for FEV1
(pre-measured or pre Rx % predicted)

FEV1 ≥ 70 mild obstruction

60 – 69 moderate obstruction
50 – 59 moderately severe obstruction
34 – 49 severe obstruction
<34 very severe obstruction
STEP 2

 Check FVC ( pre% reference or pre- Rx %

predicted values)
 If ≥ 80, there’s no probable restriction
 If< 80, there’s probable restriction, so suggest
lung volume studies
STEP 3
 Check TLC ( pre% reference or pre- Rx
% predicted values)
 If between 80 -120, there’s no definite
restriction
 If < 80, there is definite restriction

TLC ≥ 70 mild restriction

60 – 69 moderate restriction
< 60 severe restriction

STEP 4
 IfRV ( pre% reference or pre- Rx %
predicted values) > 135, indicative
of air trapping
STEP 5
 IfTLC and RV are increased,
indicative of hyperinflation
STEP 6
 IfSRAW ( pre% reference or pre- Rx
% predicted values) >120 indicative
of increased airway resistance
STEP 7
 Check DLCO ( pre% reference or pre-
Rx % predicted values)

 If > 80, normal

 If ≤ 80, see severity of reduction

DLCO
60 – 80 mildly reduced
40 – 59 moderately reduced
< 40 severely reduced
STEP 8
 Compute for MVV
 FEV1(pre% reference or pre- Rx %
predicted values) x41 = A
 MVV ( pre% reference or pre- Rx %
predicted values) / A = B
 If B ≥ 0.8, normal
 If B ≤ 0.8, MVV is low relative to FEV1 suggestive of poor effort
and/or neuromuscular disorder


STATIC LUNG VOLUMES
 Static Lung Volumes
INDICATIONS CONTRAINDICATIONS
 Diagnose restrictive disease patterns  no absolute contraindication
 Differentiate between obstructive and  relative contraindications for
restrictive disease patterns spirometry
 Assess response to therapeutic
 factors such as claustrophobia,
interventions (e.g., transplantation,
radiation, chemotherapy, lobectomy)
upper body paralysis, obtrusive body
casts, or other conditions that
 Aid in the interpretation of other lung immobilize or prevent the patient
function tests from fitting into or gaining access to
 Make preoperative assessments in the “body box”
patients with impaired lung function that
would be affected by surgery  the procedure may necessitate
stopping intravenous therapy or
 Evaluate pulmonary disability supplemental O2.
 Quantify the amount of gas trapping by
comparing results of different techniques
 HAZARDS AND COMPLICATIONS

 Nosocomial infection contracted from improperly cleaned

tubing, mouthpieces, and pneumotachographs
 Hypoxemia from interruption of O2 therapy with the body
box
 Depressed ventilatory drive in susceptible subjects (i.e.,
CO2 retainers) as a consequence of breathing 100% O2
during the nitrogen washout
 Hypercapnia and hypoxemia during helium-dilution FRC
determinations as a consequence of failure to remove
CO2 or add O2 adequately
There are three indirect techniques to measure these lung volumes:

1. Helium dilution measure whatever gas is in the lungs

at the beginning of the test, if the gas is
2. Nitrogen washout in contact with unobstructed airways.

3. Body plethysmography measures all the gas in the thorax at

the resting expiratory volume
HELIUM DILUTION aka closed circuit method
Why use helium?
It is inert (lighter than air), colorless, odorless, tasteless gas and is not toxic. it cannot
transfer across the avleolar-capillary membrane and is thus contained when in the lungs.

1. A spirometer is normally filled with about 600 mL of gas with about 10% of Helium added
to the volume.
2. The subject is instructed to breath normally and, at the end of a normal exhalation is
connected to the system.
3. The patient rebreathes the gas in the spirometer while CO2 is removed by a CO2
absorbent.
4. Helium is then diluted until equilibrium is reached. This normally takes about 7 minutes,
but in subjects with severe lung disease, it may take as long as 30 minutes.
5. The final concentration of Helium is then recorded.
NITROGEN WASHOUT aka open-circuit method

1. The nitrogen concentration in the lungs is ~79% at the beginning of the test
which is gradually washed out as the subject rebreathes 100& O2.
2. the subject is instructed to breathe normally, and at the end of a normal
exhalation, the patient is connected to the 100% O2 breathing system.
3. During the procedure, the exhaled volume is monitored and nitrogen
percentages are measured.
4. Complete nitrogen washout occurs in about 7 minutes.
5. FRC may now be calculated by:

FRC = (Expired volume – N2) / N1

Where: N1 = Nitrogen percentage in lungs at start of test
N2 = Nitrogen percentage in lungs at end of test
 BODY PLETHYSMOGRAPHY
1. The patient is instructed to breath normally through the
mouthpiece.
2. As the patient breathes, a pressure transducer measures pressure at
the airway as well as inside the chamber.
3. An electrical shutter is used to periodically close the airway, causing
the patient to breathe against a closed airway.
 The technique of body plethysmography is based on Boyle’s Law.
4. FRC can then be calculated by:

FRC = (Atmospheric pressure x volume change) / pressure

diffusing capacity of
the lung for carbon
monoxide (DLCO)
INDICATIONS
 Evaluation and follow-up of parenchymal lung
diseases associated with dusts or drug reactions or CONTRAINDICATIONS
related to sarcoidosis
 Mental confusion or incoordination
 Evaluation and follow-up of emphysema and cystic preventing the subject from
fibrosis adequately performing the
 Differentiation between chronic bronchitis, maneuver
emphysema, and asthma in patients with
obstructive patterns
 Evaluation of pulmonary involvement in systemic  A large meal or vigorous exercise
diseases immediately before the test
 Evaluation of cardiovascular  Smoking within 24 hours of test
 Prediction of arterial desaturation during exercise in
administration (may have effect on
COPD DLCO independent of COHb)
 Evaluation and quantification of disability
associated with interstitial lung disease Evaluation of
the effects of chemotherapy agents or other drugs
known to induce pulmonary dysfunction
 Evaluation of hemorrhagic disorders
HAZARDS AND COMPLICATIONS
 DLCOSB requires breath holding at TLC; some patients may
perform either a Valsalva (high intrathoracic pressure) or
Müller (low intrathoracic pressure) maneuver. Either of
these maneuvers can result in alteration of venous return to
the heart.

 Transmission of infection is possible via improperly cleaned

mouthpieces or from the inadvertent spread of droplet
nuclei or body fluids.
DIFFUSING CAPACITY
 Sometimes called transfer factor.
 Represents the gas exchange capabilities of the lungs.
 Evaluates how well gas diffuses across the alveolar-capillary
membrane

Why Carbon monoxide?

 very high affinity for Hb (210 times greater than o2) which keeps the
pulmonary capillary partial pressure of CO (PcCO) near zero
 diffuses rapidly into the pulmonary blood. CO
DO’S DON’T’S
 Patient should be tested  should not breathe
at rest in a seated supplemental O2 for 10
position minutes before testing

 refrain from smoking on  should not have an

the day of the test. abnormal level of COHb
before the test
 Single-breath method
 Most common method for measuring the diffusing capacity
1. Patient is connected to the system in which the inspired gas contains a
mixture of 10% Helium and 0.3% Carbon monoxide.
2. Patient is instructed to exhale completely to RV level, place the
mouthpiece in the mouth, inhale as deeply as possible, hold the breath for
10 seconds, and then exhale.

Decreased DLCO – decreased surface area available for diffusion or

thickening of the alveoli itself.
- O2 toxicity, emphysema, sarcoidosis, edema, asbestosis
BRONCHOPROVOCATION
BRONCHOPROVOCATION

 includes several tests used to

diagnose asthma.
 used to identify and
characterize airway
hyperresponsiveness.
 assess changes in
hyperreactivity of the airways
or to quantify its severity.
INDICATIONS
 most often considered when asthma is a
serious possibility and traditional
methods(PRE- & POST- spirometry) have not
established or eliminated the diagnosis.

 accurate diagnosis of asthma

 assessment of the response to asthma

therapy,

 identification of triggers for cases involving

environmental or occupational exposures.
CONTRAINDICATIONS

Absolute
 Heart attack or stroke within 3 months
 Known or suspected aortic aneurysm
 Uncontrolled hypertension
 FEV1 less than 50% predicted (or <1.0 L)
Relative
 Pregnancy or nursing
 Obvious airway obstruction
 Physical or mental handicaps that prevent acceptable performance of
spirometry