Teste funcționale respiratorii

Brocovschii Victoria
Conf.univ.
Pneumologie si alergologie
SIMPLE SPIROMETRY & FLOW VOLUME
LOOPS
• Is there airflow limitation?

• How severe is it?

• Is there a response to bronchodilator therapy?

• Is there obstruction present along the major airways?

 A SPIROMETER
measuring lung volume as a function of time
 A PNEUMOTACHOGRAPH
measuring air flow as a function of lung volume
 Terminology
• VC – Vital capacity, the total amount of air that can be
expelled from the lungs from full inspiration to full expiration

• FVC – Forced vital capacity, should be the same volume as VC

but is sometimes reduced due to air trapping in COPD

• FEV1 – Forced expiratory volume in one second from full

inspiration

• FEV1/FVC or FEV1% or FEV1/FVC ratio – The percentage of

the FVC that is produced in the first second
Spirografia
FACTORS DETERMINING STATIC LUNG VOLUMES

• HEIGHT taller individuals have larger lung volumes

• GENDER males have larger lung volumes than females

• AGE in children lung volume increases with growth, in adults

lung volume is stable, with old age there is an increase in RV,
FRC & a decrease in ERV

• ETHNICITY consider Asian, Black & Inuit populations

 Patient preparation

Before arrival

• No large meal within 2 hours

• No vigorous exercise within half an hour

• Comfortable loose clothing

• Empty bladder

•?false teeth
 Patient preparation

To withhold or not to withhold medication?

If you are doing reversibility testing:
• No short acting bronchodilators for 4 hours
• No long acting bronchodilators for 12 hours
• No sustained release oral bronchodilators for 24 hours

For routine monitoring of COPD patients:

• Take all medication as usual –measure post bronchodilator.
 Explaining to the patient

• Keep it simple –
“I want to test the amount of air in your lungs and how well or
quickly it moves”

• Don’t blind the patient with science

 INDICATIONS
 To confirm or disprove lung disease suggested by
symptoms, signs or other abnormal laboratory findings
 To quantify the impact of known disease on lung function
 To measure the effects of noxious exposures
 To determine changes in lung function over time or following
treatments
 To assess the risk for surgical procedures known to affect
lung function
 To evaluate disability or impairment
 Epidemiological or clinical research on lung health or disease
 CONTRAINDICATIONS
 Absolute
• MI within the previous month
 Relative
• Hemoptysis of unknown origin
• Pneumothorax
• Unstable cardiovascular status, or pulmonary embolus
• Thoracic, abdominal, or cerebral aneurysms
• Recent eye surgery
• Presence of any acute disease process that might interfere
with test performance
• Recent thoracic or abdominal surgery
• Dementia or confusional state
 LIMITATIONS
• Test results can show abnormalities of lung function, but
these are not disease-specific.

• A reduction of vital capacity is regarded as a sign of

respiratory disease, but it cannot allow differentiation between
restriction and obstruction.

• Spirometry can detect obstructive abnormalities at relatively

early stages, but it may not be sensitive to restrictive
abnormalities before extensive damage has occurred.
 A MANOEUVER IS ACCEPTABLE, IF...
• The patient cooperates well

• A steep rise of the first part of the FVC-curve (start of test

criteria)
-Back extrapolated volume > 150 ml/5%

• A pointed peak (PEF) in the first part of expiration (start of

test
criteria)

• A “smooth” Flow-Volume curve free of artefacts

• Expiration lasts for at least 6 sec and exhibits a plateau

(end of
test criteria)
FREQUENT PROBLEMS DURING PERFORMING
FVC MANOEUVER
Cough
FREQUENT PROBLEMS DURING PERFORMING
FVC MANOEUVER

Submaximal effort
Note position of PEF!
FREQUENT PROBLEMS DURING PERFORMING
FVC MANOEUVER
Glottis closure (abrupt
end)
Expiratory time ~ 1s
 SELECTION OF THE BEST CURVE

• After having three acceptable manouevers:

-Check repeatability for FVC and FEV1
-Calculate FEV1 /FVC from the highest values
obtained
-Select the manoeuver with the highest sum of
FEV1 and FVC (all other indices i.e. flows are
taken from that manouever)
TYPES OF VENTILATORY DEFECTS
 Tipuri de disfuncție ventilatorie
Tipul obstructiv Tipul restrictiv Tipul mixt

Volumele pulmonare dinamice

Capacitatea vitală forţată (CVF) ↔ sau ↓ ↓ ↓

Volumul expirator maxim pe ↓ ↓ ↓↓

secundă (VEMS)

Indicele Tiffeneau ↓ ↔ sau ↑ ↓

(raportul VEMS/CVF)

Volumele pulmonare statice

Capacitatea pulmonară totală ↔ sau ↑ ↓ ↓
(CPT)

Volumul rezidual (VR) ↑ ↓ ↓

VR/CPT ↑ ↔
NORMAL SPIROMETRY
 ASSESSMENT OF BRONCHODILATOR TEST

• Significant response (FEV1 or FVC in comparison to baseline)

•Increase of >12%
AND
•change >200 ml

VEMS post Salbutamol – VEMS pre Salbutamol

X 100%
VEMS pre Salbutamol
 SEVERITY CLASSIFICATION

Normal Obstrucție Obstrucție Moderat- Obstrucție Foarte

ușoară moderata severă severă severă

FEV1 (VEMS) ≥70 - 75 % ≥70 % 60-69 % 50-59 35-49 <35

FEV1/FVC > 70 % <70 = obstructie

CLINICAL SITUATIONS
 N
↓
↓
 ↓
↓↓
↓↓
Body - pletismografie
Body - pletismografia
• Metodă utilizată pentru determinarea
volumelor pulmonare
• Permite efectuarea testelor funcţionale
respiratorii
• Vine să complementeze spirometria prin
măsurarea suplimentară a TLC, RV, FRC, Rtot
• Capacitatea de difuziune a gazelor (DLCO,
TLCO)
Body - pletismografie

Normal Restrictiv Air trapping Hiperinflație

Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
Pattern-ul obstructiv
Air trapping Hiperinflație

FEV1
FVC
FEV1/FVC
RV
TLC
RV/TLC
FRC
Pattern-ul restrictiv
Restricție Restricție
intrinsecă extrinsecă
FEV1
FVC
FEV1/FVC
RV
RV/TLC
TLC
FRC
Valori normale
FEV1 ≥80
FVC ≥80
FEV1/FVC 70
RV 80-140
TLC 80-120
FRC 80-120
DLCO 80-140
Curbele flux volum

Curbă obstructivă Curbă restrictivă

Transferul gazos
Transferul gazos - esența
DLCO scade în:
• Patologia circulației pulmonare (TEAP, HTP, vasculite, șunturi
arterio-venoase)
• Afecțiuni alveolare (pneumonie)
• Emfizem pulmonar
• SDRA
• Procese pulmonare fibrozante
• Procese pulmonare granulomatoase
• Rezecție pulmonară
• Patologie cardiovasculară (edem pulmonar, șunt dreapta-
stînga)
• Diverse (Anemia, Sarcina, Fumatul)
DLCO crește în:
• Efort fizic
• Sindroamele hemoragice pulmonare (sindr. Goodpasture)
• Șuntul stînga-dreapta
• Policitemia
• Astm bronșic
• Obezitatea morbidă
• Defect obstructiv
• Hiperinflație și Air Trapping
• DLCO micșorat
• Diagnostic?

PFT III 45
PFT III 47
• Defect restrictiv
• TLC și RV micșorat
• DLCO redus

• Diagnostic?

PFT III 48
PFT III 49
Importanța
Body - pletismografiei
• Diagnosticarea patologiei pulmonare
restrictive
• Diferențierea procesului obstructiv
de cel restrictiv
• Măsurarea rezistenței la flux
• Evaluarea la distanță a evoluției bolii
și răspunsului la tratament
Mulțumesc pentru atenție!!!