Professional Documents
Culture Documents
Ch3 PULMONARY PHYSIOLOGIC TESTING PDF
Ch3 PULMONARY PHYSIOLOGIC TESTING PDF
compliance, resistance, respiratory pressures, airway hyperreactivity, or bronchodilator reversibility) and those that
focus on gas exchange: arterial oxygen and carbon dioxide
partial pressures (PaO2 and PaCO2) and saturations (SaO2 and
SaCO2), alveolar-arterial oxygen pressure difference
(P[A a]O2), diffusing
(DLCO), and physiologic dead
. capacity
.
space ventilation (VD/VT). Various lung diseases, or individual variation within a given disease, may result in discordant
impairment between various mechanical properties or between
mechanical and gas exchange properties. Thus, a combination
of tests to evaluate lung mechanics and gas exchange will
provide the most comprehensive understanding.
SPIROMETRY
Spirometry is the most commonly performed and standardized measurement of pulmonary function. This test measures
the volume and ow rate of air that leaves the lungs (how
much and how fast).
Traditionally, exhaled volume is measured as a function of
time using a volume-displacement spirometer with ow rates
calculated by dividing volume into timed segments. It is now
more common for systems to primarily measure ow, with
real-time integration of ow over time to obtain volume,
owing to the development of less expensive and more compact
and accurate ow-sensing devices and fast microprocessors.
The total volume exhaled from a full inspiration (total lung
capacity [TLC]) to a full expiration (residual volume [RV])
is termed the vital capacity (VC). The maneuver can be
performed using a forced complete exhalation, referred to as
forced vital capacity (FVC), or during a slow complete exhalation, dened as slow vital capacity (SVC). Forced exhalation is necessary to assess expiratory ow rates, including
peak expiratory ow (PEF) and the volume exhaled in the
rst second (FEV1) as well as other less commonly used
timed volumes (e.g., FEV0.5, FEV3.0 [volumes exhaled in the
rst half second and the rst 3 seconds, respectively]) and
forced expiratory ows (FEF50%, FEF25-75% [forced expiratory
ow at 50% of the FVC, and forced expiratory ow between
25% and 75% of the FVC, respectively]). The parameter
FEV1 is the most reproducible and validated measure derived
from the forced expiratory maneuver and, with its ratio
FEV1/FVC, provides the foundation for lung disease classication, discussed later (Fig. 3-1).
Slow vital capacity maneuvers are used to assess other
static lung volumes and capacities such as inspiratory capacity
(IC) and expiratory reserve volume (ERV) and, because spirometry cannot measure the air remaining in the lung after a
complete exhalation, are often linked to tests of lung volume
(Fig. 3-2).
19
Ch003-F06861.indd 19
1/21/2008 10:19:55 AM
20
Section 1 Introduction
8.0
8.0
6.0
7.0
TLC
6.0
4.0
RV
TLC
2.0
FVC
3.0
FIF50
4.0
2.0
6.0
1.0
RV
0.0
8.0
7.0
4.0
5%
FVC
FEV1
257
0.0
FEF
Flow (L/s)
5.0
Volume (L)
FEF50
2.0
FEV1
6.0
5.0
2.0
3.0
Volume (L)
2.0
0.0
1.0
1.0
2.0
3.0
4.0
Time (sec)
FIGURE 3-1 Flow and time curves. A, Good duration of effort is seen on the volume-time curve by the plateau of volume change over time. In a
normal ow-volume loop, good early effort is shown by the rapid upstroke to a slightly rounded sharp peak ow. Good duration of effort is
illustrated by the upward concavity at the end of exhalation, indicating slowing of airow near residual volume. Patients with obstructive lung
disease have deeper, upward concavity throughout exhalation on the ow-volume loop. FEF50, forced expiratory ow at 50% of the forced vital
capacity (FVC); FEV1, volume exhaled in the rst second; FIF50, forced inspiratory ow at 50% of FVC; RV, reserve volume; TLC, total lung
capacity.
TABLE 3-1 Common Indications for Pulmonary Function Testing
Categorization of the type and severity of physiologic perturbation
Restrictive versus obstructive categorization
Asthma versus emphysema
IC
Ch003-F06861.indd 20
IC
IRV
TLC
SVC
TV
ERV ERV
FRC
RV
RV
RV
It is then followed by a rapid inhalation back to full inspiration. This effort can be shown graphically as a ow-volume
loop (FVL) or volume-time curve (V-t curve), both representing the same FVC maneuver (see Fig. 3-1). Enthusiastic
coaching by the technician, including appropriate body language and phrases, is necessary to get full effort from the
patient. The technician rst explains and demonstrates the
technique, instructs the patient to inhale rapidly and completely with minimal pause at full inspiration (only 1-2 s),
then instructs the subject to blast the air from the lung and
keep going, keep going, keep going until the patient has
fully exhaled. An unacceptable pause (e.g., 4-6 s) at TLC,
delaying the start of exhalation, has been shown to be associated with reductions in FEV1 and peak expiratory ow
(PEF).
1/21/2008 10:19:55 AM
21
10.0
Sharp peak
8.0
Plateau
6.0
Continuous
curve
4.0
Artifacts
(glottic closure)
Rapid rise
(blast)
4.0
Good start
Gradual return
to 0 flow
0.0
2.0
Slow rise
Abrupt end
flow
Incomplete
inhalation
Smooth
inhalation
4.0
Hesitant
start
0.0
0.0
1.0
2.0
3.0
Acceptable loop
4.0
4.0
Inadequate loop
Ch003-F06861.indd 21
1/21/2008 10:19:56 AM
22
Section 1 Introduction
Denitions
The 2005 ATS-ERS standards on lung volumes employed the
following denitions.4 A lung volume parameter is termed a
volume if it cannot be broken down into smaller subcomponents (see Fig. 3-2):
Tidal volume (VT or TV) is the volume of gas inhaled or
exhaled during the respiratory cycle.
Inspiratory reserve volume (IRV) is the maximum volume of
gas that can be inhaled from the end-inspiratory level
during tidal breathing.
Residual volume (RV) refers to the volume of gas remaining
in the lung after maximal exhalation (regardless of the lung
volume at which exhalation was started).
Ch003-F06861.indd 22
Body Plethysmography
Plethysmographic techniques have become the gold standard
for measurement of lung volumes. The patient sits in a large,
air-tight, glass-enclosed box and breathes through a mouthpiece (Fig. 3-4). During the test an electronic shutter temporarily occludes the mouthpiece and the patient continues
to pant against the closed shutter. FRC is chosen as the
starting point because the chest wall is in a relaxed state and
it thus tends to be a very reproducible value. During an
inspiratory pant against the closed airway the chest expands
slightly, creating a negative pressure swing at the alveolus that
can be measured at the mouth. Plethysmographic technique
assumes that mouth and alveolar pressures are equal, whereas
there is no ow as the subject pants against a closed shutter.
The test employs Boyles law, which states that the
product of the pressure and the volume of a gas at a given
temperature remains constant (P1 V1 = P2 V2). If the
pant begins as the shutter is closed at FRC, then (Patm
FRC) = (Patm + Pmouth) (FRC + V) where Pmouth is
the pressure swing at the mouth and V is the volume change
of the thorax. V is determined by applying Boyles law for
a second time whereby the pressure change in the air-tight
box Pbox is proportionate to the V of the chest wall.
Intuitively, an individual with a small amount of air left in
the lungs at end-expiration (small FRC) will have a higher
mouth pressure change, when panting against a closed shutter,
for a given change in thoracic volume (reected in Pbox).
1/21/2008 10:19:56 AM
23
Electrically
controlled shutter,
closed at
end-expiration
FRC
Patient makes
panting efforts
against closed
shutter
Gas Dilution
The helium dilution technique is a closed-circuit technique.
A spirometer is lled with a mixture of helium and oxygen.
The amount of helium in the spirometer (helium concentration (C1) volume of spirometer [V1]) is known at the beginning of the test. As the patient exhales to FRC, a valve
switches the patient into a closed circuit breathing from the
spirometer. Because the breathing circuit is closed (assuming
no leaks) the total volume of helium in the system remains
constant during the test. By measurement of the nal helium
concentration in the circuit after the patient has equilibrated
with the mixture (C2), FRC can be solved from the equation:
(C1 V1 = C2 (V1 + FRC)). Nitrogen washout technique
involves collection of exhaled gas as the lung is washed out
with a 100% oxygen mixture. The total volume of nitrogen
collected after complete washout is then in proportion to
the FRC.
Ch003-F06861.indd 23
1/21/2008 10:19:56 AM
24
Section 1 Introduction
IC
ERV
Mid-rest position
RV
True
FRC
O
FIGURE 3-5 Body plethysmography technique: box error. Linked FRC and SVC maneuver performed suboptimally. The SVC portion was well
performed as demonstrated by the slowing of ow near full lung ination and near full exhalation demonstrating full inspiratory effort and full
expiratory effort. The quiet tidal breathing portion (left side of curve) did not settle down a stable end-expiratory baseline for establishing FRC.
When the shutter closes in the body plethysmograph, the measurement of VLpleth (thoracic gas volume during body box) may be correct but the
lack of a prior stable end-expiratory point to dene FRC will also result in incorrect values for FRC, and also ERV and IC, which are referenced to
the point of FRC. This will also result in incorrect values for TLC and RV, when derived from arithmetic use of FRC, IC, or ERV.
Diffusing Capacity
The single-breath DLCO measures the capacity of the lung to
transfer gas, using the test gas carbon monoxide (CO). Known
as the transfer factor (TLCO) in Europe, it is measured in
Ch003-F06861.indd 24
1/21/2008 10:19:56 AM
Ch003-F06861.indd 25
25
1/21/2008 10:19:57 AM
26
Section 1 Introduction
Lung Compliance
Although not a routine test in most laboratories, a more
direct way of distinguishing parenchymal lung disease from
chest wall disorders as a cause of restriction or low DLCO is
to measure lung compliance. These measurements require
placement of esophageal (balloon) catheters to measure
esophageal pressure, which reects pleural pressure across a
compliant esophagus. Patients are asked to relax against a
closed shutter attached to a manometer that measures mouth
pressure at various lung volumes. The difference between
mouth and esophageal pressure represents the elastic recoil
pressure of the lung, abbreviated PEL(L). Figure 3-6 represents typical volume-pressure curves in diseases associated
with decreased compliance (V/P), such as pulmonary
brosis (right shift), normal compliance as is also present in
chest wall abnormalities, and increased compliance such as
with emphysema (left shift). PEL(L) at TLC, also represented
as the ratio of PEL(L)/TLC and termed coefcient of retraction, is a useful representative parameter derived during this
testing. Interstitial lung disease will have a high PEL(L) at
TLC and high PEL(L)/TLC, whereas chest wall restriction
will present as a low PEL(L) but a normal PEL(L)/TLC. This
low PEL(L) in chest wall restriction (e.g., due to pleural
restriction, kyphoscoliosis, neuromuscular weakness) is due
to underexpansion of a normal lung, held to low lung volumes
by the extrapulmonary process. By contrast, the very low
PEL(L) at TLC resulting in low PEL(L)/TLC seen in emphysema is a reection of the intrinsic loss of elasticity. The
normal range for PEL(L)/TLC is 2 to 8 cm H2O/L.
Another way of representing this value allows better recognition of the physiologic components that contribute to
maximal oxygen delivery and oxygen extraction.
VO2max = heart rate(max) stroke volume(max) 1.34 Hgb
SaO2 muscle extraction rate(max)
Volume (L)
Normal
3
Fibrosis
2
.
Increases in minute ventilation (VE) during exertion are necessary to maintain systemic blood gas and acid-base homeostasis. The formula describing the effect of changes in various
factors on minute ventilation requirements is:
0
0
30
10
20
Distending pressure (cm H2O)
40
Ch003-F06861.indd 26
.
VE = 0.86 VCO2/(PaCO2 [1 VD/VT])
1/21/2008 10:19:57 AM
.
Therefore, the rate of increase in VE is positively correlated
with the level of exertional metabolism or carbon dioxide
production (VCO2); inversely related to the arterial partial
pressure of carbon dioxide central set point (PaCO2); and
inversely associated with the proportion of tidal volume (VT)
consisting of dead space (VD) identied as the ratio VD/VT.
Lactic acidosis associated with increasing exertion .in both
normal and cardiac-impaired individuals can drive VE both
by increasing CO2 production associated with bicarbonate
buffering and through direct effects on carotid body and
central chemoreceptors.
VD/VT abnormalities are associated with most pulmonary
parenchymal and vascular disease processes due to regions of
excessive ventilation-perfusion ratio. Whereas absolute dead
space rises normally during exertion, the VD/VT falls from
0.35 at rest to less than 0.20 at maximal exertion.
An arterial blood sample is necessary to accurately calculate the dead space proportion using the equation:
VD/VT = (PaCO2 PECO2)/PaCO2
Normal
27
(MVV)
VE
VE
Ventilatory
reserve
(MVV)
Ch003-F06861.indd 27
Alveolar ventilation
VE = Minute ventilation
Dead space
1/21/2008 10:19:57 AM
28
Section 1 Introduction
HEALTHY NORMAL
6
5
Predicted
Rest
Exercise
6
4
Flow (L/s)
Flow (L/s)
1
0
COPD PATIENT
8
TLC
2
0
RV
2
4
3
4
6
5
4
3
Volume (L)
5
4
Volume (L)
rest
IC
exercise
Safety Issues
Standard safety criteria for exercise termination that have
been reported include the following13:
INTERPRETATION
Normal Reference Values
Once a test has been reviewed for quality, the next step is
to decide if individual test parameters fall within or outside
Ch003-F06861.indd 28
rest
IC
exercise
1/21/2008 10:19:57 AM
FEV1
80-120
FVC
80-120
FEV1/FVC
>0.70
FEF25-75%
TLC
80-120
FRC
75-120
RV
75-120
DLCO
75-120
*Upper and lower limits are approximate; lower and upper fth percentile or 95% condence intervals for these variables are primarily
used for deciding if a parameter is outside the normal range, with
only a secondary role for percent of predicted.
Note: absolute ratio of 0.70 not 70% of predicted ratio. The use of
a xed ratio for the lower limit is less useful than one which is based
on age, height, and sex.
DLCO, diffusing capacity; FEF, forced expiratory ow; FEV1, volume
exhaled in the rst second; FVC, forced vital capacity; FRC, functional
residual capacity; RV, residual volume; TLC, total lung capacity.
Ch003-F06861.indd 29
29
1/21/2008 10:19:58 AM
30
Section 1 Introduction
Patterns of Abnormality
Figure 3-9 offers a simplied algorithm for classifying PFT
patterns derived from the 2005 ATS-ERS standards.3
Obstructive Pattern
The distinction between obstruction and restriction is based
on the FEV1/FVC ratio (or the FEV1/VC ratio) (Figs. 3-1 and
3-10). In the 2005 ATS-ERS standards for interpretation
FEV1/VC
LLN
Yes
No
VC LLN
VC LLN
Yes
No
No
Yes
TLC LLN
Yes
TLC LLN
Yes
No
Normal
Restriction
DLCO LLN
DLCO LLN
Yes
Yes
No
PV
disorders
Normal
Obstruction
No
CW and NM
disorders
No
ILD
pneumonitis
Mixed defect
DLCO LLN
Yes
No
Asthma
CB
Emphysema
5
Flow (L/second)
c
Volume (L)
4
c
3
b
2
4
3
a
1
3
4
5
Time (seconds)
4
5
Volume (L)
FIGURE 3-10 Volume-time curves (A) and ow-volume curves (B) in normal (c), obstructed (a), and restricted (b) ventilation.
Ch003-F06861.indd 30
1/21/2008 10:19:58 AM
the assessment of airow obstruction because serial measurements of FVC requiring repeated forceful exhalations to RV
can be difcult and time consuming to obtain. The ATS-ERS
guidelines have suggested that 6 seconds is a minimum
criterion for acceptable exhalation duration (Miller et al,
2005a).1 The NHANES III reference equations have provided predicted values for FEV6 and FEV1/FEV6 in addition
to FVC and FEV1/FVC.4 One study has found the sensitivity
of FEV1/FEV6 for diagnosing airway obstruction dened by
FEV1/FVC was 95.0% and the specicity was 97.4%.25 When
interpretations differed, the measured values were near the
lower limits of the reference range. Potential advantages of
the FEV6 include better reproducibility than the FVC, more
explicit denition of the end of test point, and less physical
demand on the subject.
Restrictive Pattern
A restrictive ventilatory defect is dened as a reduction in
TLC below the 5th percentile of the predicted value, accompanied by a normal FEV1/VC. A restrictive defect may be
suspected when spirometry shows a decreased VC, the
FEV1/VC is increased (>85%-90%), and the ow-volume
curve shows a convex pattern.3 A normal or elevated FEV1/
FVC ratio with a low FEV1 or FVC suggests restriction,
although lung volumes are needed to conrm true restrictive
dysfunction. This is recommended because some with
this spirometric pattern have underlying obstructive lung
disease.3,14,26,27 This pseudorestriction in patients with
asthma or COPD is recognized by hyperination on lung
volume testing or bronchodilator responsiveness of the
restriction. By contrast, those with true restriction have
reduced lung volumes (TLC, and often also RV and FRC).
As such, VC is very sensitive for restriction but less specic.26
When examining spirometric results, the likelihood of true
restriction increases as FVC decreases and FEV1/FVC
increases.26 A normal VC is very good at ruling out
restriction.
Ch003-F06861.indd 31
31
1/21/2008 10:19:58 AM
32
Section 1 Introduction
14
12
10
Flow (L/s)
8
6
4
2
2
4
Rating of Severity
A
Expiration
4
5
6
Volume (L)
Inspiration
B
FIGURE 3-11 A, Variable extrathoracic UAO caused by vocal cord
dysfunction syndrome is evident on this ow-volume loop. The
inspiratory limb of the loop shows attening and ow rates much
below the expiratory limb. This functional disorder of vocal cord
adduction is also known as functional stridor, factitious asthma, or
laryngeal dyskinesia. Some patients have concomitant asthma, but
when vocal cord dysfunction is an asthma mimic only inspiratory
stridor is present. The ow-volume loop or laryngoscopy establishes
the diagnosis. B, Variable extrathoracic UAO. During expiration, the
transmural pressure gradient acting across the tracheal wall distends
the airway, lessening the obstruction to airow. On inspiration, the
transmural gradient causes critical narrowing and a ow plateau
develops. (FROM CLIN CHEST MED 1994; 15:35-53, 1994; ADAPTED FROM
AM J MED 61:85, 1976.)
ated with inspiration result in more normal-appearing inspiratory loops (see Fig. 3-12).
Because diseases causing UAO patterns are uncommon,
many suggestive loops will be due to poor effort or can represent a normal variant. Such poor effort is generally associated with lack of repeatability, whereas true abnormalities are
repeatable.
High-frequency utter waves (sawtoothing) are sometimes superimposed on otherwise normal FVLs in patients
with upper airway pathology. This was rst reported in
patients with obstructive sleep apnea and initially was thought
to be specic to that condition. Subsequently, it was also
Ch003-F06861.indd 32
Bronchodilator Response
ATS-ERS criteria for dening bronchodilator response considers a signicant intra-session bronchodilator response to be
an increase from baseline FEV1 or FVC greater than 12% and
200 mL.3 Testing is performed before and 10 to 15 minutes
after use of a rapid-onset bronchodilator (typically albuterol),
delivered as four puffs via a spacer device (Miller et al,
2005a).1,3 When bronchodilator responsiveness is to be
assessed, short-acting bronchodilators are stopped for 4 hours
and long-acting bronchodilators stopped for 12 to 24 hours
before the testing session. If testing is performed to assess
the patients maintenance medical regimen, bronchodilators
are not withheld. Typically, measurement of DLCO, if ordered,
will be performed during the 15-minute window after agonist administration because results are generally not
affected by the bronchodilator (Miller et al, 2005b).2,3
Bronchodilator reversibility has some clinical utility in
determining lability of lung function and conrming the presence of a xed obstructive impairment. This testing, however,
is neither highly sensitive nor specic in distinguishing asthma
from COPD, does not represent a xed characteristic in an
individual patient (because reversibility status commonly
1/21/2008 10:19:58 AM
10
10
4
Flow (L/s)
Flow (L/s)
Volume (L)
a
Expiration
Volume (L)
b
33
FIGURE 3-12 A, Left (a), Variable intrathoracic UAO in this owvolume loop was caused by a rare granular cell tumor of the distal
trachea. Because the patient presented with wheezing, asthma
was suspected. The plateau and abrupt concave-down shoulder at
the right end are typical and contrast to the scooped-upward
concavity typical of COPD or asthma. The small squeak of a peak
ow before the plateau is sometimes seen and does not rule out
UAO if a plateau of ow is present. Right (b), A normal ow-volume
loop is shown after tumor resection. B, Variable intrathoracic UAO.
The transmural pressure gradient during expiration results in
compression of the intrathoracic trachea, as it does in the lower
airways in asthma and COPD. This narrowing in the trachea results
in a ow ceiling (plateau) during expiration. During inspiration, the
gradient across the tracheal wall distends the airway and ow
limitation at this site does not occur. (MODIFIED FROM CLIN CHEST
MED 15:35-53, 1994; ADAPTED FROM AM J MED 61:85, 1976.)
Inspiration
B
changes from month to month), and is not fully reective of
the clinical utility of a given inhaled agent.29,30 Pre- and postbronchodilator lung volume testing may demonstrate signicant decreases in hyperination (reduced FRC, RV) such that
signicant improvement in ow at the same lung volume,
associated with symptomatic improvements, may be observed
despite an unchanged FEV1 and FVC.31 Quantitative comparison of ow at the same lung volumes may be a method
of integrating these concepts and is termed isovolume ow
assessment.
A less well-accepted test of bronchodilator responsiveness
is improvement in ow at low lung volumes such as FEF25-75%.
Because the midow section is always dened by the VC in
which it resides, comparisons before and after use of a bronchodilator need to be adjusted to reect ow through the
same range of volumes (isoFEF25-75%), rather than from an
unadjusted FEF25-75%. Improvement in isoFEF25-75% of 35% or
more is suggestive of bronchodilator responsiveness when
taken from a study with excellent repeatability.
Ch003-F06861.indd 33
Rating
ATS/ERS
FEV1 (%)
GOLD
FEV1 (%)
Predicted
DLCO* (%)
Mild
>70
>79
(FEV1/FVC <0.7)
Moderate
60-69
50-79
40-60
<40
Moderately severe
50-59
Severe
35-49
30-49
Very severe
<34
<30
*The rating of severity is appropriate to use after the test has been
determined to be abnormal based on a FEV1, VC, FEV1/VC, TLC, or
DLCO outside the normal range. Rating of severity of obstruction or
restriction is based on the FEV1.
ATS, American Thoracic Society; COPD, chronic obstructive pulmonary disease; DLCO, diffusing capacity; ERS, European Respiratory
Society; FEV1, volume exhaled in the rst second; LLN, lower limit of
normal.
Modied from Eur Respir J 26:948968, 2005; and www.goldcopd.org.
1/21/2008 10:19:58 AM
34
Section 1 Introduction
Neuromuscular Disease
These patients generally have a normal lung and chest wall
but weakness of the inspiratory muscles (mainly the diaphragm) and the expiratory muscles (mainly the abdominal
muscles), which limits inspiratory and expiratory deviation
from the resting lung volume (FRC). Consequently, the characteristic abnormality is a reduction in VC caused by reduction in both IC and ERV. The reduced IC, with a normal
FRC, results in a reduced TLC (and hence is restrictive).
The reduced ERV, with a normal FRC, results in an increased
RV in those with more severe weakness. This elevation of RV
in the setting of decreased VC and increased RV distinguishes
the restriction of neuromuscular disease from true restrictive disorders.
Patients with isolated or disproportionate bilateral diaphragmatic weakness or paralysis show a marked fall in VC
in the supine compared with the erect posture. This reects
the effects of gravitational forces on abdominal contents in
the two positions. In the normal subjects the VC falls 5% to
10% in the supine position. A fall of 30% or more is associated with severe diaphragmatic weakness, and the postural
fall may exceed 50% in some subjects.
Ch003-F06861.indd 34
Although the MIP and MEP are the more specic and
sensitive tests for muscle weakness, the simpler and more
accessible VC is most often followed in neuromuscular
disease patients. VC is also sensitive for assessing the progression from moderate to severe respiratory muscle weakness.
The rate of decline in VC predicts survival in both amyotrophic lateral sclerosis and Duchenne muscular dystrophy.
Although, in general, MVV has no advantages over VC, in
some patients with Parkinsons disease the MVV may be
reduced disproportionately to VC.
Pseudorestriction Associated
With Obesity and Asthma
Patients with obesity or asthma may have spirometric ndings that may be confused with those associated with true
restrictive disorders. FVC may be low with a normal or elevated FEV1/FVC ratio.
With obesity, the associated reduction in chest wall and
abdominal compliance also results in a mild fall in VC as well
as FRC and TLC.34 In contrast to true restriction, however,
abdominal compression of the lower lung leads to early airway
closure and a low ERV with elevated RV and reduced midexpiratory ow (FEF25-75%).35
Clues to distinguish a pseudorestrictive pattern in asthma
from true restriction and from the pseudorestriction of
obesity include the following:
1/21/2008 10:19:59 AM
Ch003-F06861.indd 35
35
pulmonary congestion. In mild stages, with vascular congestion but without frank pulmonary edema, the increased capillary blood volume will result in an increased DLCO. With
more blood volume (and hemoglobin) to accept CO and
nothing interfering with the transfer of gas from alveolus to
capillary, uptake of CO is enhanced. As congestion worsens
with the development of interstitial and alveolar edema, a
restrictive process with a reduced DLCO develops.39 In
chronic congestive heart failure, pericapillary hemosiderosis
and brosis can result in a stable drop in DLCO.40
Amiodarone pulmonary toxicity is a difcult diagnosis to
establish. Although serial PFTs, including the measurement
of DLCO, have not proven useful in screening for early disease,
otherwise unexplained restriction and low DLCO is part of
the clinical pattern suggesting toxicity from this drug.
Bronchoprovocation
FEV1 and PEF rate are good measures of asthma severity and
measure the degree of airow obstruction. A related but distinct aspect of asthma is the degree of twitchiness of the
airways, known as airway hyperresponsiveness. This tendency
to bronchoconstriction can be assessed for specic antigens,
although it is more common to assess nonspecic hyperresponsiveness in the laboratory with pharmacologic agents
(methacholine or histamine), exercise (exercise-induced
bronchospasm), or cold dry air inhalation (which is often
combined with exercise). Although these techniques are
complementary in yield, the pharmacologic agent methacholine is most frequently used.
1/21/2008 10:19:59 AM
36
Section 1 Introduction
Exercise Bronchoprovocation
Assessment for exercise-induced bronchospasm can be performed as an add-on to CPET or as a separate diagnostic
maneuver. Testing for EIA in the laboratory is only moderately sensitive because conditions may not mimic the cold
and dry air conditions or the pattern of ventilation present
under eld conditions. Therefore, methacholine challenge
testing always needs to be the rst bronchoprovocation study,
even in subjects with suspected exercise-induced bronchospasm, because it is also simpler to perform and more
sensitive for the diagnosis. Some patients will demonstrate
hyperresponsiveness to exercise or cold air challenge testing
who do not react to methacholine. Exercise bronchoprovocation is best performed on the treadmill, with a target heart
rate of 80% to 90% of predicted maximum (220 age in
years) maintained for 4 to 6 minutes, with a total exercise
duration of 6 to 8 minutes. Spirometry measurements are
made before and then every 5 minutes for 20 minutes after
the exercise maneuver.42 A drop in FEV1 of greater than 15%
Assessment of Intervention
Cardiopulmonary exercise testing has shown promise in the
research and clinical arenas in the assessment of physiologic
and functional change associated with an intervention. CPET
not only offers greater insight into specic physiologic changes
than resting testing but also allows assessment of the integrated response of varying effects of the intervention on the
system. For example, in the assessment of exercise response
to lung volume reduction surgery, a given individual may
demonstrate increased tidal volume and lower respiratory
NORMAL RESPONSE
VO2 max %
71%
HR %pred
95%
VE-max/MVV
0.62
AT % VO2 pred
50%
O2 pulse
92
BE
PCO2
34
VD/VT
0.21
180
100
HR 1/min
98%
140
60
100
20
60
1000
Ch003-F06861.indd 36
VE L/min
FEV1 %pred
2000
3000
VO2 mL/min
1/21/2008 10:19:59 AM
VO2 max %
66%
HR %pred
102%
VE-max/MVV
0.47
AT % VO2 pred
39%
O2 pulse
58
BE
PCO2
32
VD/VT
0.24
180
100
140
HR 1/min
87%
VE L/min
FEV1 %pred
37
60
100
20
60
1000
2000
3000
VO2 mL/min
PURE VENTILATORY LIMITATION
47%
VO2 max %
62%
HR %pred
77%
VE-max/MVV
0.92
NA
O2 pulse
81
BE
PCO2
48
VD/VT
0.47
100
140
60
100
VE L/min
AT % VO2 pred
180
HR 1/min
FEV1 %pred
20
60
1000
2000
3000
VO2 mL/min
VO2 max %
72%
HR %pred
98%
VE-max/MVV
0.53
AT % VO2 pred
36%
O2 pulse
62
BE
PCO2
26
VD/VT
0.42
180
100
140
HR 1/min
97%
60
100
20
60
1000
Ch003-F06861.indd 37
VE L/min
FEV1 %pred
2000
3000
VO2 mL/min
1/21/2008 10:19:59 AM
38
Section 1 Introduction
DETERMINATION OF PROGNOSIS
Measurements of maximal oxygen consumption are predictive of survival in individuals with cystic brosis, congestive
heart
failure, and COPD.50 Patients with cystic brosis with
.
VO2peak less than 59% predicted were more than three times
as likely to die as those with values greater than 82% of predicted, whereas measures of resting pulmonary function did
not independently correlate with survival.51 Individuals with
cardiomyopathy
awaiting heart transplantation who have
.
VO2peak greater than 14 mL/min/kg demonstrate a 94% oneyear survival compared with 70% of those individuals with
52
values less than 14 mL/min/kg.
Based on these data, indi.
viduals with values for VO2peak less than 14 are prioritized
in consideration for heart transplantation.
The National Emphysema Treatment Trial stratied severe
emphysema patients into subgroups, based on patterns of
exercise response. Patients who had a high mortality rate in
the control group based on low incremental cycle ergometry
watts (dened earlier) experienced a greater than 50% reduction in mortality rate if they had upper lobe dominant disease,
whereas patients in the high-exercise category were not
likely to experience a survival benet. The high-exercise
responders, however, still experienced improved exercise tolerance and quality of life if they had upper lobe dominant
disease. The role for CPET measurements in the assessment
of preoperative risk before thoracotomy are . discussed
in Chapter 2, and in this situation low maximal VO2 measures can dene subgroups of
. patients at excessively high
risk for surgery, and higher VO2 measures dene subgroups
at acceptable risk despite traditionally unacceptable FEV1
levels.53-55
Disability Assessment
Although clear guidelines for determination of disability are
lacking, it is clear that resting pulmonary function measurements do not adequately predict functional status. In a group
of subjects studied who met ATS guidelines for respiratory
disability, 48% had slight or no disability measured using
CPET.56 One standard commonly used in determination of
disability is to compare oxygen consumption measurements
in the laboratory to published energy requirements for
Ch003-F06861.indd 38
Pulmonary Rehabilitation
The use of CPET before pulmonary rehabilitation is recommended to dene safety and determine exercise prescription.
CPET allows supervised observation of potential ischemia,
arrhythmia, and desaturation before training sessions.58-60
KEY REFERENCES
American Thoracic Society: Single-breath carbon monoxide diffusing
capacity. Recommendations for a standard technique; 1995 update.
Am J Respir Crit Care Med 152(6 pt 1):2185-2198, 1995.
American Thoracic Society/American College of Chest Physicians:
ATS/ACCP Statement on cardiopulmonary exercise testing. Am J
Respir Crit Care Med 167:211-277, 2003.
Crapo RO, Casaburi R, Coodes AL, et al: Guideline for methacholine
and exercise challenge testing1999. This ofcial statement of the
American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med 161:309-329, 2000.
Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force:
Standardisation of spirometry. Eur Respir J 26:319-338, 2005a.
Miller M, Crapo R, Hankinson J, et al; ATS/ERS Task Force: General
considerations for lung function testing. ATS/ERS Task Force. Eur
Respir J 26:153-161, 2005b.
1/21/2008 10:20:00 AM