Flow-Volume Loops - UpToDate

18/8/2019 Flow-volume loops - UpToDate
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Flow-volume loops
Authors: Loutfi Sami Aboussouan, MD, James K Stoller, MD, MS
Section Editors: Peter J Barnes, DM, DSc, FRCP, FRS, Robert A Wood, MD
Deputy Editor: Helen Hollingsworth, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2019. | This topic last updated: Feb 22, 2019.
INTRODUCTION
Spirometry, which includes measurement of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), is
the most readily available and most useful pulmonary function test. The flow-volume loop is a plot of inspiratory and expiratory
flow (on the Y-axis) against volume (on the X-axis) during the performance of maximally forced inspiratory and expiratory
maneuvers.
Changes in the contour of the loop can aid in the diagnosis and localization of airway obstruction [1]. Characteristic flow-volume
loop patterns are also often found in certain forms of restrictive disease, although flow-volume studies are not considered
primary diagnostic aids in the evaluation of these disorders.
An overview of flow-volume loops will be presented here. General reviews of pulmonary function testing in adults and children
and performance of spirometry are provided separately. (See "Office spirometry" and "Overview of pulmonary function testing in
adults" and "Overview of pulmonary function testing in children" and "Pulmonary function testing in asthma".)
NORMAL FLOW-VOLUME LOOP
The flow-volume loop is a plot of inspiratory and expiratory flow (on the Y-axis) against volume (on the X-axis) during the
performance of maximally forced inspiratory and expiratory maneuvers (figure 1). The patient is instructed to take a full
inspiration (to total lung capacity), exhale forcefully and completely into the mouthpiece (to residual volume [RV]), and then
inspire forcefully and fully back to total lung capacity. Typically, a flow-volume loop needs to be requested specifically, as an
order for "spirometry" frequently yields just the expiratory portion. (See "Overview of pulmonary function testing in adults",
section on 'Flow-volume loop'.)
The normal expiratory portion of the flow-volume curve is characterized by a rapid rise to the peak flow rate, followed by a nearly
linear fall in flow as the patient exhales toward RV (figure 1). The inspiratory curve, in contrast, is a relatively symmetrical,
saddle-shaped curve. The flow rate at the midpoint of vital capacity (between total lung capacity and residual volume), known as
the forced expiratory flow-50 (FEF50), is normally slightly less than the flow rate at the midpoint of inspiration, known as the
forced inspiratory flow-50 (FIF50). Thus, the ratio FEF50/FIF50 is normally <1.
CLINICAL USE OF FLOW-VOLUME LOOP
The utility of flow-volume loops for detection of obstructing lesions of the upper airway was first reported by Miller and Hyatt, who
described three distinct patterns: variable extrathoracic obstruction; variable intrathoracic obstruction; and fixed obstruction
(figure 1 and figure 2 and figure 3) [2]. When evaluating patients with dyspnea or noisy breathing, the contour of the flow-volume
loop can provide additional information about the location of airway constriction, beyond that provided by the numeric values for
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forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) [3]. However, the sensitivity is low for mild
obstruction and interpretation can be hampered by overlapping diseases (eg, chronic obstructive pulmonary disease [COPD] and
tracheal stenosis). Furthermore, airway lesions at the thoracic inlet can move between the intrathoracic and extrathoracic
compartments (see 'Variable obstruction at the thoracic inlet' below). Thus, positive and negative findings should be confirmed
with imaging and/or direct visualization.
Identification of upper airway lesions — The flow-volume loop test is simple and readily available, whenever an upper airway
lesion is suspected (figure 1 and figure 2 and figure 3) [4]. For the purposes of this discussion, the upper airway is defined as
that portion of the airway extending from the mouth to the mainstem bronchi. The upper airway is divided into intra- and
extrathoracic components by the thoracic inlet, which projects 1 to 3 cm above the suprasternal notch on the anterior chest at the
level of the first thoracic vertebra.
In a retrospective review of 2662 flow-volume loops, 123 (4.6 percent) had abnormalities of the inspiratory flow-volume curve
(consisting of truncation, flattening or absent loop) [5]. Further evaluation of 21 (17 percent) of the identified inspiratory
abnormalities led to a specific etiology in 11 (52 percent), including vocal cord dysfunction, vocal fold paralysis, and other
conditions. In this study, abnormalities were detected more often among patients with more than one abnormal inspiratory curve
in a pulmonary function testing session, suggesting that functional and anatomic assessment is particularly useful when more
than one flow-volume curve attempt is abnormal. (See "Clinical presentation, diagnostic evaluation, and management of central
airway obstruction in adults".)
Limitations — The flow-volume loop is an insensitive test for upper airway obstruction, as lesions must narrow the tracheal
lumen to less than 8 mm (a reduction of the tracheal area by at least 80 percent) before abnormalities can be detected (figure 4)
and some types of obstruction only become apparent with provocation (eg, noxious stimuli, exercise) [2,6,7]. Depending on the
degree of suspicion, absence of an abnormality in a patient with exertional dyspnea should be further evaluated with direct
visualization (eg, imaging, laryngoscopy, flexible bronchoscopy) and/or cardiopulmonary exercise testing, which may be
combined with sequential flow-volume loops or direct visualization during exercise. (See 'Exercise flow-volume loops' below.)
The most common cause of an abnormal inspiratory loop is submaximal patient performance either due to lack of effort or
insufficient coaching [7]. Evidence demonstrating the insensitivity of flow-volume loops for detecting upper airway obstruction in
various settings includes the following:
● Upper airway obstruction – In a study of 475 flow-volume loops, the aggregate sensitivity of several quantitative and visual
criteria for upper airway obstruction was 69.4 percent and the areas of the receiver operating curves for all the individual
criteria were low (ie, receiver-operating-characteristic [ROC] <0.522) [8].
● Vocal fold dysfunction – In a study of 226 patients who underwent laryngoscopy, the accuracy of flow-volume loops for
detecting vocal fold dysfunction was evaluated [9]. Assessment of flow-volume loops by a pulmonologist had low predictive
value (ROC <0.68), leading to the conclusion that a normal flow-volume loop should not preempt laryngoscopy when vocal
fold dysfunction is suspected. Another study found that patients with inducible laryngeal obstruction (ILO, also called
paradoxical vocal fold dysfunction [PVFM]) and subglottic stenosis could be differentiated by specific measurements derived
from the flow-volume loop, with peak expiratory flow (PEF) being higher and FEV1/PEF being lower in patients with ILO [10].
(See "Paradoxical vocal fold motion", section on 'Evaluation and diagnosis'.)
● Tracheobronchomalacia – In an evaluation of 76 flow-volume loops in subjects with symptomatic tracheobronchomalacia,

13 (17 percent) had no flow-volume loop abnormalities [11]. (See "Tracheomalacia and tracheobronchomalacia in adults",
section on 'Diagnosis'.)
ABNORMAL EXPIRATORY LOOP
Abnormalities in the contour of the expiratory flow-volume loop depend in part on the size and location of the airway that is
narrowed. Patterns include diffuse truncation of the expiratory curve in intrathoracic tracheal narrowing, a biphasic pattern in
tracheomalacia, a concave upward curve in diffuse lower airways disease (eg, asthma, chronic obstructive pulmonary disease
[COPD]), a narrow curve in restrictive disease, and a "saw-tooth" irregularity in neuromuscular disease. (See 'Saw-tooth pattern'
below.)
Variable intrathoracic obstruction — This pattern, also known as dynamic or non-fixed intrathoracic obstruction, demonstrates
truncation (flattening) of the envelope of the maximal expiratory curve, due to expiratory flow limitation (figure 1). The pleural
pressure surrounding the intrathoracic trachea is negative relative to the intratracheal pressure during inspiration, thereby
producing no restraint to inspiratory airflow. In contrast, flow limitation is encountered during forced expiration, when the pleural
pressure becomes positive relative to airway pressure, and the effect of any obstructive lesion in this region is accentuated
(figure 2).
Turbulent flow and a Venturi effect may result in a further drop in airway pressure, adding to airway narrowing and flow limitation.
The FEF50/FIF50 ratio is reduced, with an average value of 0.32 (figure 1) [12]. This pattern may occur with tracheomalacia of the
intrathoracic airway, bronchogenic cysts, or with tracheal lesions, which are often malignant [12,13]. An early expiratory notch
has been described in a patient with a glomus tumor of the trachea [14]. In the case of a goiter, intrathoracic obstruction may
only become evident if spirometry is performed with arm elevation (known as Pemberton sign) [15]. This may be true of other
causes of intrathoracic obstruction as well.
Intrathoracic tracheobronchomalacia — A variety of flow-volume patterns have been described with intrathoracic
tracheobronchomalacia: biphasic with a sharp narrow peak followed by a flat tail, a notched expiratory loop, and an oscillatory
contour (figure 5) [11]. The peak expiratory flow rate is typically lower than normal. (See "Tracheomalacia and
tracheobronchomalacia in adults", section on 'Pulmonary function tests'.)
Mainstem bronchial obstruction — Several abnormalities in the expiratory flow-volume loop have been described in patients
with unilateral mainstem bronchial obstruction. Total functional obstruction of a mainstem bronchus results in an apparent
restrictive ventilatory pattern of the expiratory curve, reflecting the loss of function of the affected side (figure 6) [16].
On the other hand, a partially occluded bronchus may result in a mixed obstructive and restrictive pattern. This would
presumably result from initial normal emptying of the unaffected side, followed by slow emptying of the affected side. The net
effect is an increasing upward concavity at lower lung volumes, as occurs with asthma or emphysema [16]. However, these
patterns may be masked in patients with underlying emphysema [17].
Other patterns that may be seen with differential emptying include:
● An end-inspiratory tail (figure 7) [18,19]

● A biphasic spirogram, with an initial normal curvature of the expiratory loop and a "straight line" appearance at end-
expiration (figure 7) [18]
● A flattening or plateau of the initial portion of the expiratory flow curve [20]
Lower airway obstruction — A frequently recognized abnormality in the flow-volume loop is the concave upward, or "scooped-
out" or "coved," pattern encountered in asthma, COPD, bronchiectasis, and bronchiolitis (figure 1). Maximal expiratory flow rates
during the latter two-thirds of an expiratory maneuver are largely effort independent (ie, flow cannot be accelerated by increased
expiratory effort), and vary directly with the elastic recoil of the lung and inversely with the airway resistance upstream of the
equal pressure point.
Two changes are present in emphysema that will reduce flow rate during this phase of respiration: the elastic recoil of the lung is
decreased due to loss of lung parenchyma; and airway resistance is increased due to secretions, bronchospasm, or narrowing of
small airways.
The concave upward appearance of the flow-volume loop in obstructive lung disease probably results from the following two
factors:
● Compression of the major central airway with a precipitous decline in flows. This process is often referred to as negative
effort-dependence and results in excessive airway compression and premature airway closure. This may be more
prominent in patients with emphysema, and is due to loss of airway support from the tethering effect of the surrounding
parenchyma.
● A disproportionate decrease in flow later in expiration. Specifically, the heterogeneity of lung disease results in the more
rapid and earlier emptying of areas with higher elastic recoil or lower airway resistance, compared with the slower emptying
of more diseased areas.
Narrow expiratory loop in restrictive disease — The flow-volume loop has a recognizable pattern in restrictive lung or chest
wall diseases that are associated with increased elastic recoil of the respiratory system. The characteristic pattern, which is seen
most frequently with interstitial lung disease, is a decrease in vital capacity, with supernormal expiratory flows when corrected for
lung volume. The resulting shape of the flow-volume curve is a tall, "witch's hat" appearance with a steep descending limb (figure
8). (See "Overview of pulmonary function testing in adults", section on 'Restrictive ventilatory defect'.)
Normal variant "knee pattern" — In contrast to the concave inflection commonly noted in patients with obstructive lung
disease, the "knee" pattern is a normal variant representing a convex inflection in the expiratory portion of a flow-volume loop
(figure 9). The prevalence of this finding on post-bronchodilator loops is 70 percent at age 18, and decreases by age 38 to 58
percent in women and 41 percent in men [21]. The convexity in the expiratory flow has been attributed to a proximal flow-limiting
(choke point) section of the bronchial tree that moves distally with age due to loss of parenchymal elastic recoil [21].
ABNORMAL INSPIRATORY LOOP
Variable extrathoracic obstruction — The flow-volume loop pattern associated with dynamic (non-fixed) extrathoracic
obstruction (eg, vocal fold paralysis, extrathoracic tracheomalacia, polychondritis, mobile tumors) is characterized by truncation
of the envelope of the maximal inspiratory curve (figure 1). During thoracic expansion with inspiration, the combination of
atmospheric extraluminal pressure and negative (subatmospheric) intraluminal pressure results in decreased luminal size of the
extrathoracic portion of the upper airway, thus accentuating the effect of any obstructive lesion in this region (figure 3).
Turbulent flow and a Venturi effect also contribute to the drop in intratracheal pressure, producing further narrowing and flow
limitation. In addition, the ratio of expiratory to inspiratory flow at 50 percent vital capacity (FEF50/FIF50) is elevated, with an
average value of 2.2 (normal ratio <1) (figure 1) [12]. Diseases that exhibit this pattern include structural or functional vocal fold
abnormalities, laryngomalacia, and tracheomalacia of the extrathoracic trachea. (See "Paradoxical vocal fold motion".)
Extrathoracic tracheomalacia is associated with flattening of the inspiratory curve and an increase in the FEF50/FIF50 to 1.4 to
1.8 [22]. (See "Tracheomalacia and tracheobronchomalacia in adults".)
ABNORMAL INSPIRATORY AND EXPIRATORY LOOPS
Fixed upper airway obstruction — Firm tracheal lesions (eg, tracheal stenosis) can limit the modulating effect of transmural
pressures on airway luminal diameter with the result that flow is limited during both inspiration and expiration, causing
flattening of both limbs of the flow-volume loop. An FEF50/FIF50 ratio close to 1 (average 0.9) has been observed as a
characteristic of fixed upper or central airway obstruction (figure 1) [12].
Dynamic narrowing of airway segments adjacent to the obstructive lesion may skew this ratio depending upon its location. One
report, for example, evaluated patients with rigid thoracic lesions [22]:
● A ratio greater than 1.3 was noted in three of six patients with rigid extrathoracic lesions. Cinefluoroscopy suggested that the
greater inspiratory limitation resulted from dynamic compression of the normal extrathoracic trachea between the stenotic
segment and the thoracic inlet (ie, caudad to the stenosis).
● A ratio below 0.5 was seen in one patient with a rigid intrathoracic lesion. Cinefluoroscopy confirmed that the greater
expiratory limitation was secondary to dynamic narrowing of the normal intrathoracic trachea between the stenotic segment
and the thoracic inlet (ie, cephalad to the stenosis).
● A ratio of 1 would be expected for fixed lesions at the thoracic inlet or with a noncompliant trachea [22]. Examples of fixed
upper airway obstruction include tracheal stenosis (as from prolonged intubation) or a goiter compressing the trachea.
Of note, severe chronic obstructive pulmonary disease (COPD) with a marked decrease in flow rates can obscure the expected
truncation of the flow-volume loop or produce a mixed pattern with an early narrow peak on expiration, overall reduced expiratory
flow without a clear plateau, and reduced inspiratory flow, also without a plateau [22].
Extraluminal tracheal obstruction — Extraluminal intrathoracic airway obstruction can cause a pattern of fixed airway
obstruction or an atypical pattern of extrathoracic obstruction. As an example, one series described the flow-volume loops of
patients with bulky mediastinal adenopathy due to Hodgkin lymphoma [23]. None of these patients had evidence of extrathoracic
airway involvement on computed tomographic studies. Fourteen of 25 patients (56 percent) had abnormal flow-volume loops; the
abnormalities consisted of flattening of both limbs of the flow-volume loop (seven patients) or flattening of the inspiratory loop
only (seven patients) (figure 1). While the former pattern is consistent with a fixed airway obstruction, the latter is unexpected in
intrathoracic disease. Moreover, the FEF (50 percent)/FIF (50 percent) was unexpectedly elevated in all, including those with a
fixed pattern of obstruction, which is more typical of extrathoracic obstruction. It is possible that the bulky mediastinal adenopathy
resulted in external splinting of the airway, which may have prevented the usual dynamic changes (figure 2), limiting both the
narrowing of the intrathoracic airway in expiration and the widening of the airway in inspiration [23].
Variable obstruction at the thoracic inlet — This form of upper airway obstruction may result in a double hump (also called
twin hump) of the expiratory curve as the narrowing moves from an intrathoracic to a relative extrathoracic location toward the
end of expiration (figure 10) [12,22,24]. Inspiratory slowing is often present in addition [22]. Interestingly, repeated flow-volume
loops may show first an intrathoracic and then an extrathoracic location, as the lesion moves within the chest with neck flexion
and outside the thoracic inlet with neck extension (figure 11) [24].
Examples of such lesions include low post-tracheostomy scars or strictures that may be located at or above the suprasternal
notch [12,24]. A similar double hump pattern in the contour of the expiratory curve has been described in a patient with vocal
cord dysfunction characterized by initial adduction and subsequent abduction of the vocal cords in mid-expiration [25].
Saw-tooth pattern — A so-called "saw-tooth" pattern has been described that consists of small, rapid oscillations in flow during
both expiration and inspiration (figure 12) [26,27]. Detecting the saw-tooth pattern is subjective and artifacts in the resonance
frequency of the recording equipment can have a similar appearance [28,29].
Conditions associated with a saw-tooth pattern on the flow-volume loop include neuromuscular diseases [30], Parkinson disease
[31], laryngeal dyskinesia [32], pedunculated tumors of the upper airway [33], tracheobronchomalacia [11,34], upper airway
burns [35], and obstructive sleep apnea (OSA) [26-28]. The saw-tooth pattern has also been described in 31 percent of snorers
without sleep apnea and in 10 percent of normal individuals [35,36]. Among 401 patients referred for evaluation of snoring, the
sensitivity and specificity of the saw-tooth pattern for OSA were 11 and 94 percent, respectively [36].
Another feature of flow-volume loops sometimes seen in patients with OSA is an increased ratio of FEF50/FIF50. Normally, the
FEF50/FIF50 is ≤1, but in patients with sleep apnea, it is often >1. When this criterion was examined in a group of 405 patients
referred for evaluation of OSA, the sensitivity and specificity were 12 and 86 percent, respectively [28].
EXERCISE FLOW-VOLUME LOOPS
Patients with inducible laryngeal obstruction (paradoxical vocal fold motion) often have symptoms during exercise, but not at
rest, or following exposure to a noxious stimulus. Sometimes, flow-volume loops performed after induction of symptoms by
exercise or noxious stimuli can identify flow limitation during inspiration, expiration, or both [37], including the development of a
cigar-shaped, tall, narrow loop [38]. However, the correlation of pre- and post-exercise flow-volume loops with findings on direct
visualization is poor [39-41]. As an example, in a series of 100 patients, findings on continuous laryngoscopy during exercise
testing did not correlate with the pre- and post-exercise shape of the flow-volume loop or the ratio of expiratory to inspiratory flow
at 50 percent vital capacity (FEF50/FIF50) [39]. Nonetheless, if direct visualization during or immediately after exercise is not
available, flow-volume loop data may be helpful. (See "Exercise-induced laryngeal obstruction", section on 'Continuous
laryngoscopy during exercise'.)
Patients with COPD who develop excessive concavity of the expiratory loop during exercise have been shown to be more likely
to develop dynamic hyperinflation [42].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Pulmonary function testing".)
SUMMARY AND RECOMMENDATIONS
● The flow-volume loop is a plot of expiratory and inspiratory flow (on the Y-axis) against volume (on the X-axis) during the
performance of maximal forced expiratory and inspiratory maneuvers between total lung capacity and residual volume
(figure 1). (See 'Normal flow-volume loop' above.)
● The contour of the flow-volume loop provides additional information about the location of airway constriction, beyond that
provided by the numeric values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). (See
'Introduction' above.)
● Patients with airflow limitation due to asthma or chronic obstructive pulmonary disease (COPD) often have a concave
upward pattern, sometimes called "scooped-out" or "coved," on the expiratory portion of the flow-volume loop (figure 1).
(See 'Lower airway obstruction' above.)
● For the purposes of this discussion, the upper airway is defined as that portion of the airway extending from the mouth to the
mainstem bronchi. It is further divided into intra- and extrathoracic components by the thoracic inlet, which projects 1 to 3 cm
above the suprasternal notch on the anterior chest at the level of the first thoracic vertebra. (See 'Abnormal inspiratory loop'
above.)
● The contour of the flow-volume loop is particularly useful for defining whether an obstructing lesion of the upper airway is
intrathoracic or extrathoracic and also whether it is fixed (eg, tracheal stenosis, goiter, tumor) (figure 1) or dynamic (eg,
structural and functional vocal cord abnormalities, laryngomalacia, extrathoracic tracheomalacia) (figure 3 and figure 2).
(See 'Abnormal inspiratory loop' above.)
● However, the flow-volume loop is an insensitive test for upper airway obstruction, as lesions must narrow the tracheal lumen
to less than 8 mm (a reduction of the tracheal area by at least 80 percent) before abnormalities can be detected (figure 4).
(See 'Limitations' above.)
● An abnormal inspiratory flow-volume loop should prompt a clinical assessment and review of all the flow-volume loops of the
current and previous sessions. In general, abnormalities of the upper airway need radiographic and/or direct visualization for
confirmation. (See 'Limitations' above.)
● The characteristic flow-volume loop pattern of restrictive disease (seen most frequently with interstitial lung disease) is a
decrease in vital capacity combined with supernormal expiratory flows when corrected for lung volume. The resulting shape
of the flow-volume curve is a tall, "witch's hat" appearance with a steep descending limb (figure 8). (See 'Narrow expiratory
loop in restrictive disease' above.)
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Topic 1465 Version 13.0
GRAPHICS
Flow-volume loops in upper airway obstruction
The configuration of the flow-volume loop can help distinguish the site of airway narrowing. The airways are divided into
intrathoracic and extrathoracic components by the thoracic inlet.
(A) Normal flow-volume loop: the expiratory portion of the flow-volume curve is characterized by a rapid rise to the
peak flow rate, followed by a nearly linear fall in flow. The inspiratory curve is a relatively symmetrical, saddle-shaped
curve.
(B) Dynamic (or variable, nonfixed) extrathoracic obstruction: flow limitation and flattening are noted on the inspiratory
limb of the loop.
(C) Dynamic (or variable, nonfixed) intrathoracic obstruction: flow limitation and flattening are noted on the expiratory
limb of the loop.
(D) Fixed upper airway obstruction (can be intrathoracic or extrathoracic): flow limitation and flattening are noted in
both the inspiratory and expiratory limbs of the flow-volume loop.
(E) Peripheral or lower airways obstruction: expiratory limb demonstrates concave upward, also called "scooped-out" or
"coved" pattern.
TLC: total lung capacity; RV: residual volume.
Adapted from: Stoller JK. Spirometry: a key diagnostic test in pulmonary medicine. Cleve Clin J Med 1992; 59:75.
Graphic 76811 Version 7.0
Effect of dynamic intrathoracic airway obstruction
Left panel, during forced expiration, the intrathoracic intratracheal pressure (P tr ) is less than the
pleural pressure (P pl ), worsening the obstruction. Right panel, during forced inspiration, P tr
exceeds P pl , lessening the degree of obstruction.
Redrawn from: Kryger M, Bode F, Antic R, et al. Am J Med 1976; 61:85.
Effect of dynamic extrathoracic airway obstruction
Effects of forced expiration and inspiration in dynamic extrathoracic airway obstruction. Left panel,
during forced expiration, intratracheal pressure (P tr ) exceeds the pressure around the airway
(P atm ), lessening the obstruction. Right panel, during forced inspiration, when P tr falls below P atm ,
the obstruction worsens resulting in flow limitation.
Redrawn from: Kryger M, Bode F, Antic R, et al. Am J Med 1976; 61:85.
Flow-volume loop and degree of upper airway narrowing
Volume (as liters [L] from total lung capacity [TLC]) is plotted against
inspiratory and expiratory flows. The blue line (C) is the control effort; the
number on each curve refers to the orifice diameter in mm. Lesions must
narrow the tracheal lumen to less than 8 mm before abnormalities can be
detected by spirometry.
Redrawn from Miller RD, Hyatt RE. Obstructing lesions of the larynx and trachea:
clinical and physiologic characteristics. Mayo Clin Proc 1969; 44:145.
Flow-volume loop characteristics in tracheomalacia
(A) Flow-volume loop in a patient with tracheomalacia demonstrating biphasic morphology with typical obstructive pattern.
(B) A notched expiratory loop in a different patient is shown.
(C) Expiratory oscillations from a third patient are shown.
FEF: forced expiratory flow.
Reproduced with permission of the American Association for Respiratory Care, from: Majid A, Sosa AF, Ernst A, et al. Pulmonary function and flow-volume loop
patterns in patients with tracheobronchomalacia. Respir Care 2013; 58:1521; permission conveyed through Copyright Clearance Center, Inc. Copyright © 2013.
Functional mainstem bronchial obstruction
Maximal expiratory and inspiratory flow-volume loops before (inner dashed-line

loop) and after (outer solid-line loop) surgery in a patient with mainstem
bronchial obstruction. The diameter of the orifice at the site of maximal
obstruction both before and after treatment is shown in relation to the
corresponding flow-volume loop. Note the relatively parallel rightward shift of
the descending limb of the maximal expiratory flow-volume curve after
treatment.
Flow-volume loop in left mainstem bronchial obstruction
Maximum flow-volume curves of patient before insertion of a stent in a

narrowed left main bronchus. Both an end-inspiratory tail and a biphasic
spirogram are seen.
V E MAX: forced expiratory flow; V I MAX: forced inspiratory flow.
Common patterns on flow-volume loops
The flow-volume loops are plotted against absolute lung volume to show the influence of changes in lung volume. For both
loops in each panel, the leftward intersection with the horizontal axis is at total lung capacity (TLC, maximal inhalation) and
the rightward intersection is at residual volume (RV, maximal exhalation).
(A) Patient with airflow limitation (solid lines) compared to predicted (dashed lines).
(B) Patient with mixed disease with reduced airflow and reduced lung volumes. It is important to note that if one only
measures airflow, this mixed picture would have been missed.
(C) The flow-volume loop observed in a patient with restrictive disease where the increased recoil causes increased airflow.
(D) Consistent truncation of the inspiratory phase of the loop, characteristic of a variable extrathoracic obstruction, eg,
tracheal collapse as might be due to intubation trauma.
(E) Another extrathoracic process of a more transient nature characteristic of vocal cord dysfunction.
(F) Consistent truncation of both inspiration and expiration, characteristic of a fixed obstruction, eg, tracheal stenosis.
TLC: total lung capacity; RV: residual volume; ILO: inducible laryngeal obstruction.
Expiratory flow-volume curve showing "knee" pattern
Expiratory flow-volume curve showing a "knee" pattern, which is considered to

be a normal variant most commonly seen in young adults.
Modified from:
1. Shin HH, Sears MR, Hancox RJ. Prevalence and correlates of a 'knee' pattern
on the maximal expiratory flow-volume loop in young adults. Respirology
2014; 19:1052.
2. Johnston R. What’s a normal Flow-volume Loop? PFT Blog. Available at:
http://www.pftforum.com/blog/whats-a-normal-flow-volume-loop (Accessed
on July 7, 2016).
Flow-volume loop and variable obstruction at the

thoracic inlet
Flow-volume loop in variable obstruction at the thoracic inlet showing a double

hump in the expiratory curve as the narrowing moves from an intrathoracic to a
relative extrathoracic location toward the end of expiration.
TLC: total lung capacity; RV: residual volume; L: liters.
Effect of neck movement with variable thoracic inlet

obstruction
Flow-volume loops in variable thoracic inlet obstruction with the neck flexed (A)
and with the neck extended (B). The loops show an intrathoracic and then an
extrathoracic location, as the lesion moves within the chest with neck flexion
and outside the thoracic inlet with neck extension.
TLC: total lung capacity; RV: residual volume: L: liters.
Flow-volume loop in obstructive sleep apnea
Flow-volume loop in obstructive sleep apnea showing a saw-tooth pattern. The

intersections with the x-axis are at total lung capacity (TLC) on the left and
residual volume (RV) on the right.
Contributor Disclosures
Loutfi Sami Aboussouan, MD Nothing to disclose James K Stoller, MD, MS Grant/Research/Clinical Trial Support: Alpha-1 Foundation
[Alpha-1 antitrypsin detection (Pooled human alpha-1 antiprotease)]. Consultant/Advisory Boards: CSL Behring; Grifols; Shire [Alpha-1
antitrypsin detection (Pooled human alpha-1 antiprotease)]; Arrowhead Pharmaceuticals [Alpha-1 antitrypsin deficiency]; Vertex; Inhibrx;
23andMe [Alpha-1 antitrypsin deficiency]; Alpha-1 Foundation [Member, Board of Directors (Alpha-1 antitrypsin deficiency)]; American
Respiratory Care Foundation [Member, Board of Directors (Respiratory therapy issues)]. Peter J Barnes, DM, DSc, FRCP,
FRS Grant/Research/Clinical Trial Support: AstraZeneca [Asthma, COPD (Symbicort)]; Novartis [COPD (Indacaterol)]; Boehringer [COPD
(Tiotropium, olodaterol)]; Chiesi [Asthma, COPD (Foster)]. Speaker's Bureau: AstraZeneca [Asthma (Symbicort)]; Novartis [COPD (Indacaterol,
glucopyrolate, Ultibro)]; Boehringer [COPD (Tiotropium, olodaterol)]; Chiesi [Asthma (Foster)]. Consultant/Advisory Board: AstraZeneca
[Asthma, COPD]; Novartis [COPD]; Boehringer [COPD]; Teva [COPD]; Pieris [Asthma]. Robert A Wood, MD Grant/Research/Clinical Trial
Support: DBV Technologies; Aimmune; Astellas; HAL-Allergy; Sanofi; Regeneron [Food allergy]. Helen Hollingsworth, MD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-
level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
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NORMAL FLOW-VOLUME LOOP

CLINICAL USE OF FLOW-VOLUME LOOP

● Tracheobronchomalacia – In an evaluation of 76 flow-volume loops in subjects with symptomatic tracheobronchomalacia,

ABNORMAL EXPIRATORY LOOP

Other patterns that may be seen with differential emptying include:

● An end-inspiratory tail (figure 7) [18,19]

ABNORMAL INSPIRATORY LOOP

ABNORMAL INSPIRATORY AND EXPIRATORY LOOPS

EXERCISE FLOW-VOLUME LOOPS

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

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Topic 1465 Version 13.0

Flow-volume loops in upper airway obstruction

TLC: total lung capacity; RV: residual volume.

Graphic 76811 Version 7.0

Effect of dynamic intrathoracic airway obstruction

Redrawn from: Kryger M, Bode F, Antic R, et al. Am J Med 1976; 61:85.

Graphic 55931 Version 4.0

Effect of dynamic extrathoracic airway obstruction

Redrawn from: Kryger M, Bode F, Antic R, et al. Am J Med 1976; 61:85.

Graphic 65386 Version 4.0

Flow-volume loop and degree of upper airway narrowing

TLC: total lung capacity; RV: residual volume.

Graphic 73686 Version 4.0

Flow-volume loop characteristics in tracheomalacia

FEF: forced expiratory flow.

Graphic 106751 Version 5.0

Functional mainstem bronchial obstruction

Maximal expiratory and inspiratory flow-volume loops before (inner dashed-line

Graphic 76796 Version 2.0

Flow-volume loop in left mainstem bronchial obstruction

Maximum flow-volume curves of patient before insertion of a stent in a

V E MAX: forced expiratory flow; V I MAX: forced inspiratory flow.

Graphic 74178 Version 3.0

Common patterns on flow-volume loops

Graphic 80042 Version 3.0

Expiratory flow-volume curve showing "knee" pattern

Expiratory flow-volume curve showing a "knee" pattern, which is considered to

TLC: total lung capacity; RV: residual volume.

Graphic 108135 Version 1.0

Flow-volume loop and variable obstruction at the

Flow-volume loop in variable obstruction at the thoracic inlet showing a double

TLC: total lung capacity; RV: residual volume; L: liters.

Graphic 54799 Version 2.0

Effect of neck movement with variable thoracic inlet

TLC: total lung capacity; RV: residual volume: L: liters.

Graphic 78259 Version 2.0

Flow-volume loop in obstructive sleep apnea

Flow-volume loop in obstructive sleep apnea showing a saw-tooth pattern. The

Graphic 56090 Version 5.0

Conflict of interest policy

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