Pulmonary Function Test

PULMONARY
FUNCTION TEST
• KMG
Pulmonary Function Test
• Provide important quantitative information about lung

function
• The key component :
1. Static lung volume
2. Dynamic lung function (Spirometry)
3. Diffusion capacity (DLCO)

• Other PFTs :
• Bronchodilator response
• Exercise testing : walking and climbing stairs
Most PFT result reported in predicted value calculated

from : body size, sex, age , and race
INDICATION
• FEV1 was an independent predictor of
respiratory complications
• FEV1 30% had an incidence of respiratory
morbidity as high as 43%, whereas those with an

FEV1 60% had a morbidity rate of 12%
• Diffusing capacity for carbon monoxide (DLCO) as

a useful marker of operative risk
• DLCO 60% predicted was associated with a 25%

mortality and a 40% pulmonary morbidity
Brunelli A, Kim AW, Berger KI, et al. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery. ACCP guidelines chestnet. 2013
Ranu H, Wilde M, Madden B. Pulmonary Function Tests. Department of Cardiothoracic Medicine, St George’s Hospital NHS Trust and St George’s Medical School, University of
CONTRAINDICATION
Suboptimal results may be obtained in
patients who have chest or abdominal pain
or from patients who do not fully
understand directions given to perform the
tests
Patients with active respiratory
infections such as tuberculosis are not
precluded from having PFTS however the
tests should ideally be deferred until the risk
of cross contamination is negligible
London. 2011
Pulmonary Volume
• Tidal Volume
volume of air inspired or expired with each normal breath (500 ml)
• Inspiratory Reserve Volume
extra volume of air that can be inspired over and above the normal tidal volume when the
person inspires with full force (3000 ml)
• Expiratory Reserve Volume
the maximum extra volume of air that can be expired by forceful expiration after the end of
a normal tidal expiration (1100 ml)
• Residual Volume
the volume of air remaining in the lungs after the most forceful expiration (1200 ml)
Guyton Arthur C. Medical Physiology : Respiration Pulmonary Volumes and Capacities. Elsevier Inc. 2006
Pulmonary Capacities
• Inspiratory Capacity (VT + IRV)
amount of air a person can breathe in, beginning at the normal expiratory level and distending
the lungs to the maximum amount (3500 ml)
• Functional Residual Capacity (ERV + RV)
amount of air that remains in the lungs at the end of normal expiration (2300 ml)
• Vital Capacity (IRV + VT + ERV)
the maximum amount of air a person can expel from the lungs after first filling the lungs to
their maximum extent and then expiring to the maximum extent (4600 ml)
• Total Lung Capacity (VC + RV)
The maximum volume to which the lungs can be expanded with the greatest possible effort
(5800 ml)
Calculation :
VC = IRV+VT +ERV
VC = IC + ERV
TLC = VC + RV
TLC = IC + FRC
FRC = ERV + RV
Minute Respiratory Volume
Total amount of new air moved into the respiratory

passages each minute :
VT x RR/minute
500 x 12/minute = 6 L/min
Alveolar Ventilation
The total volume of new air entering the alveoli and adjacent
gas exchange areas each minute
Respiratory rate times the amount of new air that enters these areas with
each breath
VA = Freq x (VT –VD)

VA = volume of alveolar ventilation per minute
Freq = frequency of respiration per minute
VT = tidal volume
VD = physiologic dead space volume (normal dead space 150 ml)
Determining the concentrations of oxygen and carbon dioxide in the

alveoli
• FEV1
• DLCO
• Predicted Postoperative (ppo) --> ppo-FEV1 and ppo-

DLCO
Sugarbaker D, Bueno R, Colson Y.L, et al. Adult Chest Surgery Preoperative Evaluation of Thoracic Surgery Patient. McGraw-Hill Education. 2015
SPIROMETRY
Measure of volume against time
Simple and Quicka
Procedure :
Patients are asked to take a maximal inspiration and

then to forcefully expel air for as long and as quickly
as possible (a forced vital capacity manoeuvre
• Forced expiratory volume in one second (FEV1)
• Forced vital capacity (FVC)
• The ratio of the two volumes (FEV1/FVC)
Normal FEV1/FVC Value > 80%
Measurement :
Calculation of FEV1/FVC allows the identification of obstructive, restrictive or mixed
Obstructive
A FEV1/FVC < 70 % where FEV1 is reduced more than FVC
signifies an obstructive defect. Common examples of obstructive defects
include chronic obstructive pulmonary disease (COPD) and asthma
Restrictive
FEV1/FVC > 70% or normal where FVC is reduced more so
than FEV1 is seen in restrictive defects such as interstitial lung
diseases ex : pulmonary fibrosis and chest wall deformities
London. 2011
Portch D, McCormick. Pulmonary Function Tests and Assessment for Lung Resection. Update in Anaesthesia
Volume-Time Plot and Flow-Volume loop
Example:
Obstructive
Example:
Restrictive
Hsiang FT, Travis SH, Srihari V, et al. Pulmonary Function Test. RSNA 2017
Diffusing Capacity for Carbon Monoxide
(DLCO)
Provides a measurement that indicates the functional surface area of the
bronchial tree and the efficiency of the gas diffusion across the alveolar-
capillary membrane
DLCO is reduced by :
• Impaired diffusion - i.e. increased thickness (lung fibrosis)
• Decreased area (lung resection, emphysema)
• Reduction in the ability to combine with blood (e.g. anemia)
The diffusion of gas across the alveolar membrane which is determined by the
surface area and integrity of the alveolar membrane and the
pulmonary vascular bed
London. 2011
DLCO
• Using a single breath of a mixture containing 10% helium and a low concentration of
carbon monoxide (0.3%)
• The patient holds their breath for ten to twenty seconds and then exhales
• The first 750ml of exhaled (dead space) gas is discarded and the following litre is analysed
• Helium is not absorbed by the lungs, so the helium concentration in the expired gas can be
used to calculate the initial concentration of carbon monoxide
• Therefore the amount that has been absorbed across the alveolar-capillary membrane per
minute is calculated
• This represents the diffusing capacity in mmol. kPa -1.min-1
• Carbon monoxide is used because of its high affinity for haemoglobin
DLCO
• The Correlation between spirometric values and DLCO is
relative poor (some patient with normal spirometry,
DLCO is < 40% predicted)
• Decrease in DLCO occur after lung resection
• 20% for wedge resection
• 30% for lobectomy
• 41% for pneumonectomy

Locicero J, Feins R.H, Colson Y,. Shields General Thoracic Surgery Pulmonary Physiologic Assesment of Operative Risk 8th edition. Wolters Kluwer 2019
• PULMONARY FUNCTION TESTS
AND
LUNG RESECTION
• The British Thoracic Society guidelines advise that pneumonectomy with FEV1 > 2.0 L and
lobectomy if FEV1> 1.5 L in the absence of any interstitial lung disease or unexpected disability due to
shortness of breath
• Values may be lower in older patients and women, patients are generally considered suitable for resection if
FEV1> 80% predicted and DLCO > 80% predicted
Armstrong P, Congleton J, Fountain W, et al. Guidelines On The Selection of Patients with Lung Cancer Surgery. British Thoracic Society and Society of Cardiothoracic Surgeons of
Great Britain and Ireland Working Party
Calculating the predicted postoperative
FEV1 (ppoFEV1) & DLCO (ppoDLCO)
• Five lung lobes containing nineteen

segments
• Number of segments of lung that will

be lost by resection allows the surgeon
and anaesthetist to estimate the
post-resection spirometry and
DLCO values
• Resection of the left upper or right

lower lobe, both of which have five
segments, has the greatest impact
on predicted post- resection
values
Lung Segment
In some instances, for example when the tumour is near to the hilum or in close proximity to the fissure
between lobes, it may remain unclear whether surgery will involve single lobectomy, bi-lobectomy or
pneumonectomy, until the surgeon has gained surgical access to the patient’s chest
In this situation the anaesthetist and surgeon must have estimated in advance, which of these procedures the
patient will be able to tolerate peri- and postoperatively.
Suitability for Lung Resection
Brunelli A, Kim AW, Berger KI, et al. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery. ACCP guidelines chestnet. 2013
Guidelines on the selection of patients with lung cancer for surgery
Armstrong P, Congleton J, Fountain W, et al. Guidelines On The Selection of Patients with Lung Cancer Surgery. British Thoracic Society and Society of Cardiothoracic Surgeons of
Great Britain and Ireland Working Party
Armstrong P, Congleton J, Fountain
W, et al. Guidelines On The Selection
of Patients with Lung Cancer
Surgery. British Thoracic Society and
Society of Cardiothoracic Surgeons
of Great Britain and Ireland Working
Party
Case 1 Example
A 57-year-old man is booked for right thoracotomy and lung
resection. He has lost 8kg in weight but is otherwise fit and well.
Chest Xray and CT chest show a large right upper lobe mass with
distal collapse/consolidation of most of the right upper lobe
(Figure 11). Transmural biopsies from the right main bronchus via
flexible bronchoscopy have confirmed the mass is a carcinoma.
His pulmonary function tests (Table 3) show that his spirometry

values are near normal, but that his TLCO is significantly reduced
to 55.5% of the predicted value for his sex, age and height.
The surgeon plans to perform a right upper lobectomy, but may consider upper and middle bi-lobectomy or pneumonectomy
depending on his findings at thoracotomy.
In terms of his ventilatory function, as indicated by his spirometry readings, he would be expected to tolerate
lobectomy, or pneumonectomy without too much difficulty. However the calculations in Table 4a show that his
predicted postoperative TLCO after pneumonectomy mean that adequate oxygenation will not be achievable without
oxygen therapy.
Case 2 Example
A 65-year-old woman requires pneumonectomy for non-small cell carcinoma of the right lung. Her preoperative
pulmonary function tests are shown in Table 5 and predicted post resection levels of FEV 1 and TLCO are borderline.
However her CXR and CT suggest that significant parts of her right lung may be non-functional.
This can be determined using a ventilation scan, which

demonstrates that the relative contribution of her right
and left lungs to ventilation (and therefore to spirometry
testing) is 36% to 64%. Her predicted post-
pneumonectomy values for FEV1 and TLCO can then be
calculated by multiplying the pre- resection values by
0.64 (64%). These values are 41.6% for the FEV and
45.4% for the TLCO, representing far more acceptable
values to proceed with pneumonectomy.
Exercise Tests and Oxygen Uptake
•Stair climbing and (Cardiopulmonary Exercise Testing)
6-minute walk test
•Shuttle walk
The patient walks between cones 10 meters apart. A tape player sets the pace by beeping at reducing intervals
(increasing frequency). The subject walks until they cannot make it from cone to cone between the beeps, or 12
minutes has passed. Less than 250m or decrease SaO2 > 4% signifies high risk
A shuttle walk of 350m correlates with a VO2 max of 11ml.kg .min
The obvious advantages of this technique are that it is cheap and easy to perform and gives reliable information that is
directly related to clinical outcomes
Cardiopulmonary Exercise Testing - CPET
VO2 Max
This provides a functional assessment of
cardiopulmonary reserve
The subject exercises at increasing intensity on an exercise

bike or treadmill, while inspired and expired O 2 and CO2 are
measured and an ECG is recorded. The main values of interest
are the maximum O2 uptake (VO2 max) and the anaerobic
threshold (the level at which anaerobic respiration begins).
The information gained from CPET testing allows

quantification of the predicted risks of surgery,
however this information is of limited value in the context of a
disease process where mortality approaches 100% without
surgery.
VO2 Max
VO2 max is the maximum oxygen uptake per kg body weight per minute. It is the most
useful predictor of outcome in lung resection
The maximum oxygen uptake (VO2 max) and maximum oxygen delivery to the tissues give us information
about the body’s physiological reserve and our ability to deal with the extra metabolic demands
of surgery
VO2 max are dependent on the body’s cardiac and respiratory systems. The point at which oxygen
consumption exceeds oxygen uptake is known as the anaerobic threshold. It is the level at which the
oxygen delivery required by the tissues to maintain aerobic metabolism is no longer met and anaerobic
metabolism occurs.
Above this level, energy production is much less efficient and lactic acid is produced, causing metabolic
acidosis.
VO2 Max
The information gained from CPEX testing allows quantification of the
predicted risks of surgery
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PULMONARY

• Provide important quantitative information about lung

• The key component :

1. Static lung volume

2. Dynamic lung function (Spirometry)

3. Diffusion capacity (DLCO)

• Exercise testing : walking and climbing stairs

Most PFT result reported in predicted value calculated

• FEV1 30% had an incidence of respiratory

morbidity as high as 43%, whereas those with an

• Diffusing capacity for carbon monoxide (DLCO) as

• DLCO 60% predicted was associated with a 25%

Patients with active respiratory

infections such as tuberculosis are not

precluded from having PFTS however the

tests should ideally be deferred until the risk

of cross contamination is negligible

• Inspiratory Reserve Volume

• Expiratory Reserve Volume

• Functional Residual Capacity (ERV + RV)

• Vital Capacity (IRV + VT + ERV)

• Total Lung Capacity (VC + RV)

Total amount of new air moved into the respiratory

500 x 12/minute = 6 L/min

VA = Freq x (VT –VD)

Freq = frequency of respiration per minute

VD = physiologic dead space volume (normal dead space 150 ml)

Determining the concentrations of oxygen and carbon dioxide in the

• Predicted Postoperative (ppo) --> ppo-FEV1 and ppo-

Simple and Quicka

Patients are asked to take a maximal inspiration and

• Forced expiratory volume in one second (FEV1)

• Forced vital capacity (FVC)

• The ratio of the two volumes (FEV1/FVC)

Normal FEV1/FVC Value > 80%

• Decrease in DLCO occur after lung resection

• 20% for wedge resection

• 30% for lobectomy

• 41% for pneumonectomy

• Five lung lobes containing nineteen

• Number of segments of lung that will

• Resection of the left upper or right

patient will be able to tolerate peri- and postoperatively.

His pulmonary function tests (Table 3) show that his spirometry

This can be determined using a ventilation scan, which

•Stair climbing and (Cardiopulmonary Exercise Testing)

6-minute walk test

A shuttle walk of 350m correlates with a VO2 max of 11ml.kg .min

The subject exercises at increasing intensity on an exercise

The information gained from CPET testing allows

useful predictor of outcome in lung resection

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