PULMONARYFUNCTIONTESTS

INTRODUCTION
Pulmonaryfunctiontestsisagenerictermusedto
indicateabatteryofstudiesormaneuversthatmay
beperformedusingstandardizedequipmentto
measurelungfunction.
Evaluatesoneormoreaspectsoftherespiratory
system
Respiratorymechanics
Lungparenchymalfunction/Gasexchange
Cardiopulmonaryinteraction

INDICATIONS
DIAGNOSTIC

PROGNOSTIC

Evaluationofsigns&symptoms
BLN,chronic cough,exertional
dyspnea

Assessseverity

Screeningatriskpts

Followresponsetotherapy

MeasuretheeffectofDs on
pulmonaryfunction

Determinefurthertreatmentgoals

To assesspreoperativerisk

Evaluatingdegreeofdisability

Monitorpulmonarydrugtoxicity

TISIGUIDELINES

Age>70
Obesepatients
Thoracicsurgery
Upperabdominalsurgery
Historyofcough/smoking
Anypulmonarydisease

AmericanCollegeofPhysicians
Guidelines

Lungresection
H/osmoking,dyspnoea
Cardiacsurgery
Upperabdominalsurgery
Lowerabdominalsurgery
Uncharacterizedpulmonarydisease(definedashistoryof
pulmonaryDiseaseorsymptomsandnoPFTinlast60days)

Contraindications

Recenteyesurgery
Thoracic,abdominalandcerebralaneurysms
Activehemoptysis
Pneumothorax
Unstableangina/recentMIwithin1month

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

CategorizationofPFTs
Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Physiologicaldeterminantofspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasexchangefunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

CATEGORIZATIONOFPFT
MECHANICALVENTILATORY
FUNCTIONSOFLUNG/CHESTWALL:
BEDSIDEPULMONARYFUNCTIONTESTS
STATICLUNGVOLUMES&CAPACITIES VC,IC,IRV,
ERV,RV,FRC.
DYNAMICLUNGVOLUMESFVC,FEV1,FEF2575%,
PEFR,MVV,RESP.MUSCLESTRENGTH

GAS EXCHANGETESTS:

A)Alveolararterialpo2gradient
B)Diffusioncapacity
C)Gasdistributiontests 1)singlebreathN2
test.2)MultipleBreathN2 test3)Heliumdilution
method4)RadioXe scinitigram.

CARDIOPULMONARYINTERACTION:
Qualitativetests:
1)History,examination
2)ABG
Quantitativetests
1)6minwalktest
2)Stairclimbingtest
3)Shuttlewalk
4)CPET(cardiopulmonaryexercisetesting)

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

Bed side pulmonary function tests

RESPIRATORY RATE
Essentialyetfrequentlyundervalued
componentofPFT
Impevaluatorinweaning&extubation
protocols
IncreaseRR musclefatigue workload weaningfails

Bed side pulmonary function tests

1)

Sabrasezbreathholdingtest:
Askthepatienttotakeafullbutnottoodeepbreath&hold
itaslongaspossible.

>25SEC.NORMALCardiopulmonaryReserve(CPR)

1525SEC LIMITEDCPR

<15SEC VERYPOORCPR(Contraindicationfor
electivesurgery)
25 30SEC 3500mlVC
20 25SEC 3000mlVC
15 20SEC 2500mlVC
10 15SEC 2000mlVC
5 10SEC 1500mlVC

Bed side pulmonary function tests

2)SCHNEIDERSMATCHBLOWINGTEST:MEASURESMaximum
BreathingCapacity.

Asktoblowamatchstickfromadistanceof6(15cms)
with
Mouthwideopen
Chinrested/supported
Nopurselipping
Noheadmovement
Noairmovementintheroom
Mouthandmatchatthesamelevel

Bed side pulmonary function tests

Cannotblowoutamatch
MBC<60L/min
FEV1<1.6L
Abletoblowoutamatch
MBC>60L/min
FEV1>1.6L
MODIFIEDMATCHTEST:
DISTANCEMBC
9>150L/MIN.
6>60L/MIN.
3>40L/MIN

Bed side pulmonary function tests

3)COUGHTEST:DEEPBREATHF/BYCOUGH
ABILITYTOCOUGH
STRENGTH
EFFECTIVENESS
INADEQUATECOUGHIF:FVC<20ML/KG
FEV1<15ML/KG
PEFR<200L/MIN.
*Awetproductivecough/selfpropagatedparaoxysmsof
coughing patientsusceptibleforpulmonaryComplication.

Bed side pulmonary function tests

4)FORCEDEXPIRATORYTIME:
Afterdeepbreath,exhalemaximallyandforcefully&keep
stethoscopeovertrachea&listen.
NFET 35SECS.
OBS.LUNGDIS. >6SEC
RES.LUNGDIS. <3SEC

Bed side pulmonary function tests

5)WRIGHTPEAKFLOWMETER:MeasuresPEFR(PeakExpiratory
FlowRate)
N MALES 450700L/MIN.
FEMALES 350500L/MIN.
<200L/MIN. INADEQUATECOUGHEFFICIENCY.
6)DEBONOWHISTLEBLOWINGTEST:MEASURESPEFR.
Patientblowsdownawideboretubeattheendofwhichisa
whistle,onthesideisaholewithadjustableknob.
Assubjectblowswhistleblows,leakholeisgradually
increasedtilltheintensityofwhistledisappears.
Atthelastpositionatwhichthewhistlecanbeblown,the
PEFRcanbereadoffthescale.

DEBONOSWHISTLE

Bed side pulmonary function tests

MICROSPIROMETERS MEASUREVC.

BEDSIDEPULSEOXIMETRY

ABG.

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

STATIC LUNG VOLUMES AND

CAPACITIES
SPIROMETRY:CORNERSTONEOFALLPFTs.
Johnhutchinson inventedspirometer.
Spirometryisamedicaltestthatmeasuresthe
volumeofairanindividualinhalesorexhalesasa
functionoftime.
CANTMEASURE FRC,RV,TLC

SPIROMETRYAcceptabilityCriteria
Goodstartoftest withoutanyhesitation
Nocoughing/glotticclosure
Novariableflow
Noearlytermination(>6sec)
Noairleak
Reproducibility Thetestiswithoutexcessivevariability
ThetwolargestvaluesforFVCandthetwolargestvaluesfor
FEV1 shouldvarybynomorethan0.2L.

SPIROMETRYAcceptabilityCriteria

SpirometryInterpretation:Sowhat
constitutesnormal?
Normalvaluesvaryanddependon:
I. Height Directlyproportional
II. Age Inverselyproportional
III. Gender
IV. Ethnicity

LUNGVOLUMESANDCAPACITIES

PFTtracingshave:
FourLungvolumes:tidal
volume,inspiratory reserve
volume,expiratoryreserve
volume,andresidualvolume
Fivecapacities:inspiratory
capacity,expiratorycapacity,
vitalcapacity,functionalresidual
capacity,andtotallungcapacity
Additionof2ormorevolumescompriseacapacity.

LUNGVOLUMES
TidalVolume (TV):volumeof
airinhaledorexhaledwith
eachbreathduringquiet
breathing(68ml/kg)500ml
InspiratoryReserveVolume
(IRV):maximumvolumeofair
inhaledfromtheend
inspiratorytidalposition.3000
ml
ExpiratoryReserveVolume
(ERV):maximumvolumeof
airthatcanbeexhaledfrom
restingendexpiratorytidal
position.1500ml

LUNGVOLUMES
ResidualVolume(RV):
Volumeofairremainingin
lungsaftermaximium
exhalation(2025ml/kg)
1200ml
Indirectlymeasured(FRC
ERV)
Itcannotbemeasuredby
spirometry.

LUNGCAPACITIES
TotalLungCapacity (TLC):Sumof
allvolumecompartmentsor
volumeofairinlungsafter
maximuminspiration(46L)
VitalCapacity(VC):TLCminusRV
ormaximumvolumeofair
exhaledfrommaximalinspiratory
level.(6070ml/kg)5000ml. VC~
3TIMESTVFOREFFECTIVE
COUGH
Inspiratory Capacity (IC):Sumof
IRVandTVorthemaximum
volumeofairthatcanbeinhaled
fromtheendexpiratorytidal
position.(24003800ml).
ExpiratoryCapacity(EC):TV+ERV

LUNGCAPACITIES
FunctionalResidualCapacity
(FRC):
SumofRVandERVorthe
volumeofairinthelungsat
endexpiratorytidal
position.(3035ml/kg)2500ml
Decreases
1.insupineposition(0.51L)
2.Obesepts
3.Inductionofanesthesia:by16
20%

FUNCTIONOFFRC

Oxygenstore
Bufferformaintainingasteadyarterialpo2
Partialinflationhelpspreventatelectasis
Minimizestheworkofbreathing

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

Measuring RV, FRC

Itcanbemeasuredby
nitrogenwashouttechnique
Heliumdilutionmethod
Bodyplethysmography

N2 Washout Technique

Thepatientbreathes100%oxygen,andallthe
nitrogeninthelungsiswashedout.
Theexhaledvolumeandthenitrogen
concentrationinthatvolumearemeasured.
Thedifferenceinnitrogenvolumeattheinitial
concentrationandatthefinalexhaled
concentrationallowsacalculationof
intrathoracicvolume,usuallyFRC.

Helium Dilution technique

Ptbreathesinandoutfromareservoirwithknown
volumeofgascontainingtraceofhelium.
Heliumgetsdilutedbygaspreviouslypresentinlungs.
eg:if50mlHeliumintroducedandthehelium
concentrationis1%,thenvolumeofthelungis5L.

Body Plethysmography
Plethysmography (derivedfromgreek wordmeaning
enlargement).
BasedonprincipleofBOYLESLAW(P*V=k)
Priniciple advantageoverothertwomethodisit
quantifiesnon communicatinggasvolumes.

 Apatientisplacedinasitting
positioninaclosedbodybox
withaknownvolume
Thepatientpantswithan
openglottisagainstaclosed
shuttertoproducechanges
intheboxpressure
proportionatetothevolume
ofairinthechest.
Asmeasurementsdoneat
endofexpiration,ityields
FRC

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

FORCEDSPIROMETRY/TIMEDEXPIRATORY
SPIROGRAM
Includesmeasuring:
pulmonarymechanics to
assesstheabilityofthelungto
movelargevol ofairquickly
throughtheairwaystoidentify
airwayobstruction
FVC
FEV1
SeveralFEFvalues
Forcedinspiratory rates(FIFs)
MVV

FORCEDVITALCAPACITY
TheFVCisthemaximumvolumeofairthatcanbe
breathedoutasforcefullyandrapidlyaspossible
followingamaximuminspiration.
CharacterizedbyfullinspirationtoTLCfollowedby
abruptonsetofexpirationtoRV
Indirectlyreflectsflowresistancepropertyof
airways.

FORCEDVITALCAPACITY

FVC

Interpretation of % predicted:
80-120%
Normal
70-79%
Mild reduction
50%-69%
Moderate reduction
<50%
Severe reduction

FVC

MeasurementsObtainedfromtheFVC
Curveandtheirsignificance
Forcedexpiratoryvolume
in1sec(FEV1 )the
volumeexhaledduring
thefirstsecondofthe
FVCmaneuver.
Measuresthegeneral
severityoftheairway
obstruction
Normalis34.5L

MeasurementsObtainedfromtheFVC
Curveandtheirsignificance
FEV1 Decreasedinbothobstructive&restrictivelung
disorders(ifpatientsvitalcapacityissmallerthanpredicted
FEV1).

FEV1/FVC Reducedinobstructivedisorders.
Interpretationof%predicted:
>75%
Normal
60%75%
Mildobstruction
5059%
Moderateobstruction
<49%
Severeobstruction

MeasurementsObtainedfromtheFVC
Curveandtheirsignificance

Forcedmidexpiratory flow2575%(FEF25
75)
Max.Flowrateduringthe
midexpiratorypartofFVC
maneuver.
MeasuredinL/sec
Mayreflecteffort
independentexpiration
andthestatusofthesmall
airways
Highlyvariable
DependsheavilyonFVC
Nvalue 4.55l/sec.Or300
l/min.

Forcedmidexpiratory flow2575%(FEF25
75)
Interpretationof%predicted:
>60%
Normal
4060%Mildobstruction
2040%Moderateobstruction
<10%
Severeobstruction

Peakexpiratoryflowrates
MaximumflowrateduringanFVCmaneuveroccursininitial
0.1sec
Afteramaximalinspiration,thepatientexpiresasforcefully
andquicklyashecanandthemaximumflowrateofairis
measured.
Forcedexpiratoryflowbetween2001200mlofFVC
Itgivesacrudeestimateoflungfunction,reflectinglarger
airwayfunction.
Effortdependantbutishighlyreproductive

Peakexpiratoryflowrates
Itismeasuredbyapeakflowmeter,
whichmeasureshowmuchair(litres
perminute)isbeingblownoutorby
spirometry
The peak flow rate in normal adults
varies depending on age and height.
Normal : 450 700 l/min in males
300 500 l/min in females
Clinicalsignificance valuesof<200/l
impairedcoughing&hencelikelihood
ofpostopcomplication

MaximumVoluntaryVentilation(MVV)or
maximumbreathingcapacity(MBC)
Measures speedandefficiencyoffilling&
emptyingofthelungsduringincreasedrespiratory
effort
Maximumvolumeofairthatcanbebreathedinand
outofthelungsin1minutebymaximumvoluntary
effort
Itreflectspeakventilation inphysiologicaldemands
Normal:150175l/min.ItisFEV1*35
<80% grossimpairment

MaximumVoluntaryVentilation(MVV)or
maximumbreathingcapacity(MBC)
Thesubjectisaskedtobreatheas
quicklyandasdeeplyaspossible
for12secs andthemeasured
volumeisextrapolatedto1min.
Periodslongerthan15seconds
shouldnotbeallowedbecause
prolongedhyperventilationleads
tofaintingduetoexcessive
loweringofarterialpCO2 andH+.
MVVismarkedlydecreasedin
patientswith
A. Emphysema
B. Airwayobstruction
C. Poorrespiratorymusclestrength

TOSUMMARISE

PHYSIOLOGICALDETERMINANTSOFMAX.
FLOWRATES
1)DEGREEOFEFFORT drivingpressuregeneratedbymuscle
contraction(PEmax&PImax)
2) ELASTICRECOILPRESSUREOFLUNG:(PL)
Tendencytorecoilorcollapsed/tPL
PLincreasesfromRV(23)toTLC(2030)
OpposedbyPcw(recoilpr.Ofchestwall)
Prs=Pl+Pcw=0atFRCrestingstate
(Prsrecoilpr.ofresp.system)
3)AIRWAYRESISTANCE(Raw):
Determinedbythecalibreofairways
Decreasesaslungvolincreases(hyperboliccurve)
RawhighatRV&lowatTLC

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

FLOWVOLUMELOOPS
SpirogramGraphicanalysisofflowatvariouslungvolumes
TracingobtainedwhenamaximalforcedexpirationfromTLC
toRVisfollowedbymaximalforcedinspirationbacktoTLC
Measuresforcedinspiratory andexpiratoryflowrate
Augmentsspirometryresults
Principaladvantageofflowvolumeloopsvs.typicalstandard
spirometric descriptions identifiestheprobableobstructive
flowanatomicallocation.

FLOWVOLUMELOOPS
First1/3rd ofexpiratoryflowiseffort
dependentandthefinal2/3rd near
theRViseffortindependent
Inspiratorycurveisentirelyeffort
dependent
Ratioof
maximalexpiratoryflow(MEF)
/maximalinspiratoryflow(MIF)
midVCratioandisnormally1

FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION
flowvolumeloopsprovide
informationonupperairway
obstruction:
Fixedobstruction:constant
airflowlimitationon
inspirationandexpiration
suchas
1. Benignstricture
2.Goiter
3.Endotrachealneoplasms
4.Bronchialstenosis

FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION
Variableintrathoracicobstruction:
flatteningofexpiratorylimb.
1.Tracheomalacia
2.Polychondritis
3.Tumorsoftracheaormain
bronchus
Duringforcedexpiration highpleural
pressure increasedintrathoracicpressure
decreasesairwaydiameter.Theflowvolume
loopshowsagreaterreductioninthe
expiratoryphase
Duringinspiration lowerpleuralpressure
aroundairwaytendstodecreaseobstruction

FLOWVOLUMELOOPSandDETECTIONOF
UPPERAIRWAYOBSTRUCTION
Variableextrathoracicobstruction:
1.Bilateralandunilateralvocalcord
paralysis
2.Vocalcordconstriction
3.Chronicneuromusculardisorders
4.Airwayburns
5.OSA
Forcedinspiration negativetransmural
pressureinsideairwaytendstocollapseit
Expiration positivepressureinairway
decreasesobstruction
inspiratoryflowisreducedtoagreaterextent
thanexpiratoryflow

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

ObstructivePattern Evaluation
Commonobstructivelungdiseases
Asthma
COPD(chronicbronchitis,emphysema)
Cysticfibrosis.

ASTHMA

Peakexpiratoryflowreducedso
maximumheightoftheloopis
reduced
Airflowreducesrapidlywiththe
reductioninthelungvolumes
becausetheairwaysnarrowand
theloopbecomeconcave
Concavitymaybetheindicatorof
airflowobstructionandmay
presentbeforethechangeinFEV1
orFEV1/FVC

EMPHYSEMA
Airwaysmaycollapseduring
forcedexpirationbecauseof
destructionofthesupportinglung
tissuecausingveryreducedflowat
lowlungvolumeanda
characteristic(dogleg)appearance
totheflowvolumecurve

REVERSIBILITY
ImprovementinFEV1by1215%or
200mlinrepeatingspirometryafter
treatmentwithSulbutamol2.5mgor
ipratropiumbromidebynebuliser
after1530minutes
Reversibilityisacharacterestic
featureofB.Asthma
Inchronicasthmatheremaybeonly
partialreversibilityoftheairflow
obstruction
WhileinCOPDtheairflowis
irreversiblealthoughsomecases
showedsignificantimprovement

RESTRICTIVEPATTERN
Characterizedbyreducedlung
volumes/decreasedlung
compliance
Examples:
InterstitialFibrosis
Scoliosis
Obesity
LungResection
Neuromusculardiseases
CysticFibrosis

RESTRICTIVEPATTERNflowvolumeloop

lowtotallungcapacity
lowfunctionalresidualcapacity
lowresidualvolume.
Forcedvitalcapacity(FVC)maybe
low;however,FEV1/FVCisoften
normalorgreaterthannormaldue
totheincreasedelasticrecoil
pressureofthelung.
Peakexpiratoryflowmaybe
preservedorevenhigherthan
predictedleadstotall,narrowand
steepflowvolumeloopin
expiratoryphase.

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsforgasexchangefunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

TESTSFORGASEXCHANGEFUNCTION
ALVEOLARARTERIALO2TENSIONGRADIENT:
SensitiveindicatorofdetectingregionalV/Qinequality
Nvalueinyoungadultatroomair=8mmHgtoupto25
mmHgin8th decade(d/tdecreaseinPaO2)
AbNhighvaluesatroomairisseeninasymptomaticsmokers
&chr.Bronchitis(min.symptoms)
Aagradient=PAO2 PaO2
*PAO2=alveolarPO2(calculatedfromthealveolargas
equation)
*PaO2=arterialPO2(measuredinarterialgas)
PAO2:
(PB PH2O)*FiO2 (PaCO2/RQ)

TESTSFORGASEXCHANGEFUNCTION
DIFFUSINGCAPACITY
Rateatwhichgasenterstheblooddividedbyitsdrivingpressure
(gradient alveolarandendcapillarytensions)
Measuresabilityoflungstotransportinhaledgasfromalveolito
pulmonarycapillaries
Normal 2030ml/min/mmHg
Dependson:
thickeness ofalveolarcapillarymembrane
hemoglobinconcentration
cardiacoutput

TESTSFORGASEXCHANGEFUNCTION
SINGLEBREATHTESTUSINGCO
PtinspiresadilutemixtureofCOandholdthebreathfor10secs.
COtakenupisdeterminedbyinfraredanalysis:

DlCO=COml/min/mmhg
PACO PcCO
DLO2=DLCOx1.23
WhyCO?
A) HighaffinityforHbwhichisapprox.200timesthatofO2,so
doesnotrapidlybuildupinplasma
B) UnderNconditionithaslowbldconc0
C) Therefore,pulmconc.0

FACTORSEFFECTINGDLCO
DECREASE(<80%predicted)

INCREASE(> 120140%
predicted)

Anemia
Carboxyhemoglobin
Pulmonaryembolism
Diffusepulmonaryfibrosis
Pulmonary emphysema

Polycythemia
Exercise
Congestiveheartfailure

Predicted DLCO for Hb= Predicted DLCO * (1.7 Hb/10.22 + Hb)

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

CARDIOPULMONARYINTERACTION
Stairclimbingand6minutewalktest
Thisisasimpletestthatiseasytoperformwithminimal
equipment.Interpretatedasinthefollowingtable:
Performance

VO2
Interpretation
max(ml/kg/min)

>5flightofstairs

>20

Low mortalityafter
pneumonectomy,FEV1>2l

>3flightofstairs

Lowmortalityafterlobectomy,
FEV1>1.7l

<2flightofstairs

Correlateswithhigh mortality

<1flightofstairs

<10

6minwalktest<600m

<15

CARDIOPULMONARYINTERACTION
Shuttlewalk
Thepatientwalksbetweencones10metersapartwith
increasingpace.
Thesubjectwalksuntiltheycannotmakeitfromconeto
conebetweenthebeeps.
Lessthan250mordecreaseSaO2>4%signifieshighrisk.
Ashuttlewalkof350mcorrelateswithaVO2maxof11ml.kg
1.min1

CardiopulmonaryExerciseTesting
Noninvasivetechnique
Effortindependent
Totestabilityofsubjectsphysiologicalresponseto

copewithmetabolicdemands

BasicPhysiologicalPrinciples

Exercisingmusclegetsenergyfrom3sources storedenergy
(creatine phosphate),aerobicmetabolismofglucose,
anaerobicmetabolismofglucose
Inexercisingmusclewhenoxygendemandexceedssupply
lactatestartsaccumulating lactateanaerobicthreshold(
LAT)
Withincrementalincreaseinexercise expiredminute
volume,oxygenconsumptionperminute,CO2production
perminuteincreases

WhatToMeasure

Anaerobicthreshold(>11ml/kg/min)
MaximumoxygenutilizationVO2(>20ml/kg/min)
Ventilatory equivalentofO2(<35L)
Ventilatory equivalentofCO2(<42L)
Oxygenpulse(46ml/heartbeat)

INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.

Bedsidepulmonaryfunctiontests
Staticlungvolumesandcapacities
MeasurementofFRC,RV
Dynamiclungvolumes/forcedspirometry
Flowvolumeloopsanddetectionofairwayobstruction
Flowvolumeloopandlungdiseases
Testsofgasfunction
Testsforcardiopulmonaryreserve
Preoperativeassessmentofthoracotomypatients

Assessmentoflungfunctionin
thoracotomypts
Asananesthesiologistourgoalisto:
1)toidentifyptsatriskofincreasedpostopmorbidity&
mortality
2)toidentifyptswhoneedshorttermorlongtermpostop
ventilatorysupport.
Lungresectionmaybef/by inadequategasexchange,pulm
HTN&incapacitatingdyspnoea.

Assessmentoflungfunctionin
thoracotomypts
Calculating the predicted postoperative
FEV1 (ppoFEV1) and TLCO (ppoTLCO):
There are 5 lung lobes containing
19 segments in total with the division of each
lobe.
Ppo FEV1=preoperative FEV1 * no. of segments
left after resection
19
Can be assessed by ventilation perfusion scan. For eg:
A 57-year-old man is booked for lung
resection. His CT chest show a large RUL
mass confirmed as carcinoma:
ppoFEV1= 50*16/19=42%

Assessmentoflungfunctionin
thoracotomypts
ppoFEV1(% predicted)

Interpretation

>40

Noorminorrespiratory complications
anticipated

<40

Likelytorequire postoperative
ventilation/increasedriskof
death/complication

<30

Nonsurgerymanagementshouldbe
considered

ppoDLCO(% predicted)

Interpretation

>40,ppoFEV1> 40%,SaO2>90%onair

Intermediate risk,nofurtherinvestigation
needed

<40

Increasedrespiratoryandcardiacmorbidity

<40 andppoFEV1<40%

Highrisk requirecardiopulmonaryexercise
test

Inadditiontohistory,examination,chestX ray,PFTspre op
evaluationincludes:
ventilationperfusionscintigraphy/CTscan
splitlungfunctiontests
methodshavebeendescribedtotryandsimulatethe
postoperativerespiratorysituationbyunilateralexclusionofa
lungorlobewithanendobronchialtube/blockerorby
pulmonaryarteryballoonocclusionofalungorlobeartery

Combinationtests
ThereisnosinglemeasurethatisaGoldstandard
inpredictingpostopcomplications
Threeleggedstool

Respiratory
mechanics
FEV1(ppo>40%)
MVV,RV/TLC,FVC

Cardiopulmonary
reserve
Vo2max(>15ml/kg/min)
Stairclimb>2flights,6
minwalk,
ExerciseSpo2<4%

Lungparenchymal
function
DLco(ppo>80%)
PaO2>60
Paco2<45

Pulmonaryfunctioncriteriasuggestingincreasedriskofpost
operativepulmonarycomplicationsforvarioussurgeries
Parameters

Abdominal

Thoracic

FVC

<70%predicted

<2lit.or<70%predicted

FEV1

<70%predicted

<2lit. pneumonectomy
<1lit. lobectomy
<0.6lit. wedgeorsegmentectomy

FEV1/FVC

<65% predicted

<50%predicted

FEF2575%

<50%predicted

<1.6lit. pneumonectomy
<0.6lit. lobectomy/segmentectomy

MVV/MBC

<50%predicted

<50%predicted

PaCO2

>45mm Hg

>45mm Hg

Look at flow-vol loop and any

airway obstruction pattern

FEV1 /VC >LLN

Yes

No
VC>LLN

VC>LLN

No

No
Yes

TLC>LLN

TLC>LLN
No

Normal

Restriction

DLCO>LLN
Yes

Normal

Yes

Yes

Obstruction

DLCO>LLN

No
Pulmonary
Yes
VascularDs
Neuromuscular
diseases&chest
wallds

Yes

mixeddefects

DLCO>LLN
Yes

No

No

Asthma,bronchitis

ILD&pneumonitis

No
Emphysema

Yes,PFTsarereallywonderfulbutTheydonot
actalone.
Theyactonlytosupportorexcludea
diagnosis.
Acombinationofathoroughhistoryand
physicalexam,aswellassupporting
laboratorydataandimagingishelpfulin
developingaanaestheticplanforptwith
pulmonarydysfunction.