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Medicine Noon Conference July, 2008
Frank Jacono, M.D. Pulmonary, Critical Care & Sleep Medicine
65-year old male with 3-week history of an increasingly productive cough (change in sputum color from white to yellow), increased dyspnea (shortness of breath with mild exertion ± walking to the bathroom) and wheezing. Pt denies hemoptysis, nasal discharge, sore throat or chest pain. Chronic cough which is worse in the morning. He has been on home oxygen for one year. Quit smoking 7 years ago, prior 2.5 packs/day for 40 years). Based on history, what is your diagnosis? What are risk factors for this condition?
Meds: Home O2 at 2 L/min; Tiotropium 1 inhalation daily, fluticasone MDI (110mcg) 2 puffs BID, albuterol MDI prn Exam: 37.7, 110/65, 122, 32. Audible wheezing and accessory muscle use. Chest expansion is symmetrical, hyperresonant to percussion, with diffuse wheezes and prolonged expiratory phase. ABG (2L) 7.32/58/55 What are the 5 causes of hypoxia? What would you expect to see on CXR? What would you expect to see on spirometry?
Lungs are large and hyper inflated. Signs of hyperinflation are ± Low set diaphragm ± Flat diaphragm best determined by lateral chest ± Hyper-lucent lung fields ± Increased AP diameter ± Increased retro-sternal air ± Vertical heart
Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 3.66 1.03 28 0.33 4.29
Ref 4.39 2.87 65 2.48 8.33
%Pred 83 36
Overview Pulmonary function tests are vastly under utilized ± uncomfortable with interpretation Population surveys document some abnormality in pulmonary function in 5-20% of subjects studied In a disease such as COPD. by the time dyspnea develops. airway obstruction is moderately advanced .
Common Uses of PFTs 1. 4. 5. 3. including the response to therapy To assess preoperative risk for predicting postoperative respiratory complications To screen for subclinical disease . 2. To evaluate respiratory symptoms To determine severity of impairment in patients with known respiratory disease To follow the course of disease in a patient.
Potential Shortcomings of PFT¶s Variability in the normal predicted values of various tests Requires a pulmonary function technician with considerable technical expertise. ± training ± experience Height and weight measured at the time of testing .
Standard Tests of Lung Function Spirometry: Dynamic Lung Volumes Static Lung Volumes Diffusing Capacity (DLCO) Arterial Blood Gas (ABG) .
Specialized Tests of Lung Function Bronchial challenge testing Ventilatory muscle studies Ventilatory drive studies Physiologic shunt studies Cardiopulmonary exercise testing Six minute walk .
Lung Volumes and Capacities .
followed by 3) Exhalation as hard and as fast as possible until ³all the air is out´ The volume of air exhaled is the FVC RV The remaining volume of air in the lungs is RV FVC . patient performs maximal inspiration to TLC.VolumeVolume-Time Spirogram Volume (L ) 1)Tidal volume respirations 2) At end expiration.
FlowFlow-Volume Loop FEV1 Flow-volume loop is obtained when the patient inhales quickly and deeply to TLC after completion of the FVC maneuver .
continuous exhalation maintained for at least 6 seconds. without coughing or Valsalva¶s maneuver An obvious end to the test (no change in volume for at least 2 seconds) Subject should perform a minimum of three and a maximum of eight FVC maneuvers until at least two acceptable curves are obtained The reproducibility of the two largest curves should be within 5% or 0.Acceptability Of Test A clear start to the test with an apparently maximum effort A smooth. whichever is greater The recorded FVC should be the maximum value from the acceptable curves .1 L.
± Forced vital capacity (FVC) ± Slow vital capacity (SVC) FEV1.the maximal volume of air exhaled with maximally forced effort from a position of maximal inspiration (vital capacity / TLC) performed with a maximally forced expiratory effort.Measurements Derived from Spirometry Vital Capacity (VC).the volume of air exhaled in the first second during the performance of the FVC .
75 Forced expiratory flow measured between 25% and 75% of the FVC Reflects flow in the small airways of the lung (<2mm in diameter) .Calculated Indices Volume (L ) 1 Represents flow in both large and small airways Measured directly on the volume axis after 1 second from the start of expiration 1 C Calculated ratio used to diagnose obstructive airway disease FVC 25.
FlowFlow-Volume Loop F V1 Represents flow in both large and small airways Measured directly on the volume axis after 1 second from the start of expiration FEV1 F V1 V Calculated ratio used to diagnose obstructive airway disease F F50 FIF50 Forced expiratory flow at 50% of the FVC Analogous to the FEF25-75 that was measured on the volume-time plot Forced inspiratory flow at 50% of the inspiratory vital capacity .
e. VC) implies an obstructive impairment ± (FEV1/VC < LLN) Concomitant reduction of FEV1 and VC with normal or nearly normal FEV1/VC ratio: ± Failure of patient to inhale or exhale completely ± May occur in severe obstruction when subject cannot exhale long enough to empty lungs to RV Look for normal TLC and reduced FEF75 Look for concave appearance of flow-volume curve ± Otherwise is suggestive of a restrictive impairment .e.FEV1/VC Ratio Expressed as a percentage (%) normal ratio is 70%-85% Disproportionate reduction of maximal airflow (i. FEV1) in relation to maximal volume (i.
characterized by decreased lung volumes ± reduced FVC.characterized by reductions in flow ± reduced FEV1/VC ratio below the 5th percentile of the predicted value (ATS) Often use FEV1/VC < 70% ± severity of obstruction is defined by the FEV1 percent predicted May be physiologic variant % Pred FEV1 > 100 Mild % Pred FEV1 < 100 and > 70 Moderate % Pred FEV1 < 70 and > 60 Moderately-severe % Pred FEV1 < 60 and > 50 Severe % Pred FEV1 < 50 and > 35 Very severe % Pred FEV1 < 35 FEF25-75 may show ³early changes´ but does not define obstruction ± Restrictive . and FEV1/VC ratio normal ± definitive findings requires a reduced total lung capacity (TLC) < 80% predicted .Patterns of Lung Dysfunction Defined by Spirometry Obstructive .
Classification by Severity ± GOLD Criteria goldcopd.com .
Response to Bronchodilators >12% increase in FEV1 or FVC AND >200cc increase in FEV1 or FVC .
Inspiratory data is often overlooked .Normal Flow Volume Loop Rapid peak expiratory flow rate Gradual decline in flow back to zero Inspiratory portion of the loop is a deep curve plotted on the negative portion of the flow axis.
Obstructive Airway Diseases .
Severe Obstructive Lung Disease Curve descends more quickly than normal and takes on a concave shape. the peak becomes sharper and the expiratory flow rate drops precipitously. reflected by a marked decrease in the FEF25-75. With more severe disease. .
Variable Effort .
Early Glottic Closure .
1 0. Spirometry: Meas FVC FEV1 FEV1/FVC FEF25-75 1. Data meet ATS criteria but actively wheezing during exam.Case #2 72-year old male heavy ex-smoker with chronic cough and wheezing.21 34 %Pred 61 63 .13 1.3 0.41 Ref 2.95 73.8 1.51 70.
Restrictive Lung Disease Both the FEV1 and FVC are reduced proportionately Normal or even elevated FEV1/VC ratio Overall size of the curve will appear smaller when compared to normals on the same scale Restrictive lung disease cannot be diagnosed by spirometry alone. Contrast to this loop: .
Closed-Circuit Helium Dilution 2. More complex than gas techniques.Measurement of Lung Volumes 1. Unable to use in claustrophobic or severely obese patients . More accurate than gas techniques in obstructive airway disease (bulla) Disadvantages: Expensive. Open-Circuit Nitrogen Washout 3. Body Plethysmography Advantages: Rapid measurements.
Lung Volumes and Capacities .
Lung Volumes and Capacities .
this is most reliably interpreted on the basis of the TLC Severity of the abnormality may be graded as follows: Mild Moderate Moderately-severe % Pred TLC < LLN but > 70 % Pred TLC < 70 but > 60 % Pred TLC < 60 Different mechanisms may contribute: Interstitial fibrosis ± increased elastic recoil Diaphragmatic paralysis ± respiratory muscle weakness Kyphoscoliosis ± altered chest wall configuration Pleural effusions ± compression of underlying lung parenchyma DLCO may help differentiate .Diagnosis of a Restrictive Process May be suspected based on a decreased VC without a reduction of the FEV1/FVC ratio However.
Guide to Interpreting Pulmonary Function Tests FEV1/VC < LLN (70%) ? (Actual ratio!) ** Yes: Obstructive Ventilatory Defect No: Normal or Restrictive Ventilatory Defect FVC > 80% ? TLC < LLN (80%) ? ** Yes: Pure Obstructive Defect No: May have mixed restrictive and obstructive disease Yes: Restrictive Disease No: Normal Spirometry Grade severity of obstruction based on the FEV1 percent predicted Examine Lung Volumes Grade severity of restriction based on TLC FEF25-75 < 60% or persistent symptoms ? DLCO/VA < 70 % Yes: Consider Methacholine challenge test No: Normal Yes: Intrathoracic Restriction No: Extrathoracic Restriction Test Respiratory Muscle Strength ** ATS recommends using the ³lower limit of normal´ as the cutoff (i. respectively. However. Clinical correlation is helpful. below the 5th percentile of the predicted value). Using 70% or 80%.e. this approach should be utilized with caution. . as a cutoff is reasonable in most cases.
26: 948-968 .Guide to Interpreting Pulmonary Function Tests Eur Respir J 2005.
Bedside flow-volume loop is obtained.Case #3 36-year old female recently extubated following prolonged ventilatory support during treatment for severe pneumonia and ARDS. Exam is significant for stridor. What is your diagnosis? .
FlowFlow-Volume Loop as a Diagnostic Indicator Useful as a diagnostic tool in patients with suspected upper airway obstruction Upper airway obstruction can occur at the level of: ± pharynx ± larynx ± trachea ± mainstem bronchi .
Normal Spirometry .
Fixed Obstruction 2. Variable Obstruction Intrathoracic Extrathoracic .Upper Airway Obstruction 1.
Geometry and cross-sectional area of the lesion do not change with the respiratory cycle. Variable Obstruction ± configuration of the obstructive lesion changes with the phases of respiration Intrathoracic ± lesion located below the sternal notch. bilateral vocal cord paralysis. so the expiratory limb of the flow-volume loop is predominately affected Example: tracheomalacia.Upper Airway Obstruction 1. Fixed Obstruction . so both inspiration and expiration are affected equally Example: tracheal stenosis. Wegner¶s granulomatosis Extrathoracic ± lesion located above the sternal notch. goiter 2. neoplasm. so the inspiratory limb of the flow-volume loop is predominately affected Example: vocal cord paralysis .
. bilateral vocal cord paralysis. Top and bottom of the loop are flattened so that the configuration approaches that of a rectangle. and goiter.Fixed Obstruction of the Upper Airway The fixed obstruction limits flow equally during inspiration and expiration. Examples include tracheal stenosis. and FEF = FIF.
With forced expiration. pleural pressures reach and then exceed intratracheal pressures.Variable Intrathoracic Obstruction During a forced inspiration. An example is tracheomalacia. . and the loss of structural support results in narrowing of the trachea and a plateau of diminished flow. A brief period of maintained flow is seen before airway compression occurs. negative pleural pressure holds the "floppy" trachea open.
. Thus. and expiratory flow is unimpaired. resulting in a plateau of decreased inspiratory flow. intratracheal pressure becomes less than atmospheric pressure.Variable Extrathoracic Obstruction During forced expiration. during forced inspiration. Conversely. tracheal pressure exceeds atmospheric pressure. The obstruction is drawn inward. FIF<FEF. An example is vocal cord paralysis. The obstruction is passively blown aside.
98 70 2.62 1.43 4.48 %Pred 93 73 FEV1/FVC 55 FEF25-75 PEF 0.45 Ref 2.82 1.20 5.50 20 82 . Meas FVC FEV1 2.Sample PFT #1 A 75 year old female has a history of dyspnea and palpitations.
82 5.85 72 2. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 2.20 %Pred 85 97 82 109 .20 1.Sample PFT #2 A 66 year old female complains of cough after dust exposure.58 1.67 Ref 2.79 81 1.23 5.
10 %Pred 103 74 40 71 .94 3.08 2.Sample PFT #3 A 53 year old female has a history of chest tightness.66 52 1. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 5.49 Ref 4.47 9.40 6.58 72 3.
33 72 3.28 8.85 0.28 3.82 Ref 4. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 1.92 50 0.Sample PFT #4 A 55 year old male is evaluated preoperatively for cataract surgery.55 %Pred 40 28 9 45 .60 3.
78 1.45 %Pred 101 100 40 88 .75 1.35 5.82 Ref 2.95 4.90 69 2. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 2.Sample PFT #5 A 66 year old male retired firefighter presents for wheezing with exertion.90 69 0.
29 Ref 4.87 65 2. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 3.39 2.03 28 0.66 1.48 8.33 %Pred 83 36 13 52 .33 4.Sample PFT #6 A 75 year old female is pre-operatively evaluated for mastectomy.
92 %Pred 63 77 109 102 .Sample PFT #7 A 65 year old male complains of dyspnea after mitral valve replacement.97 8.54 85 3.12 Ref 4. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 3.25 9.28 69 2.79 3.00 2.
Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 3.15 2.77 78 4.20 6.25 %Pred 103 83 51 38 .39 Ref 3.66 2.30 63 2.Sample PFT #8 A 38 year old female complains of wheezing on exertion.54 2.
Sample PFT #9 A 26 year old woman with a hoarse voice complains of shortness of breath.85 7.06 %Pred 95 94 83 80 .21 5.28 80 3.11 3.47 80 3. Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 4.63 Ref 4.34 3.
27 Ref 4.65 8.06 %Pred 96 68 18 78 . Meas FVC FEV1 FEV1/FVC FEF25-75 PEF 4.Sample PFT #10 A 69 year old male has a chronic cough.95 48 0.88 68 2.25 2.48 6.09 1.
G lobal Initiative for Chronic O bstructive L ung D isease .
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