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INVESTIGATIONS IN PULMONARY DISEASES

Objectives: after attending the lab you will be able to:

1. Interpret the values of static and dynamic lung volumes
2. Recognize the existence of obstructive and restrictive ventilatory dysfunctions
3. To list the main conditions causing ventilatory dysfunction
4. To interpret changes of PEFR

Pulmonary functional testing in respiratory diseases include:

(1) tests of pulmonary ventilation provided by spirometry
(2) assessment of lung flow rates provided by flow-volume curve
(3) tests of gas exchange with the measurement of the diffusing capacity for carbon monoxide
(4) global tests, with the analysis of respiratory gases in the arterial blood and the acid-base balance.

1. Tests of pulmonary ventilation

Pulmonary function testing starts with the most frequently used test: spirometry, a powerful tool able to detect, follow,
and manage patients with lung disorders. Lately, spirometry is reliable and relatively simple, but it does not lead
clinicians directly to an etiological diagnosis. Spirometry can be used in diagnosis of pulmonary disorders (assessing
pulmonary function), but enables also monitoring of patients with pulmonary diseases and may be also used as a
screening tool and in clinical research.
Spirometers are devices in which the subjects breathe via a mouthpiece, and the inspired and expired air volumes are
recorded as a function of time. Modern spirometers automatically correct these volumes at the conditions of
temperature, pressure and water vapor saturation of the lungs. The determination is performed in the morning, on an
empty stomach, with the patient not being allowed to smoke at least one hour before the investigation. After applying a
nose clip, in order to prevent breathing through the nose, the patient is connected to the spirometer and asked to
breathe normally for 1 minute. Next, the patient is asked to perform maximal inspiration followed by an exhale as slowly
and completely as possible. The recorded lung volumes look as in figure 1.

Figure 1. Lung volumes

The volume of air circulated during resting breathing is the tidal volume (TV).
The volume of air expelled from the lungs during peak expiration is the vital capacity (VC).
Normal values: 80-120% of ideal VC.
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The inspiratory reserve volume (IRV) is the volume of additional air that can be inhaled through a maximal inspiration,
stating from the resting inspiratory level.
The expiratory reserve volume (ERV) is the volume of additional air that can be exhaled through a maximal expiration,
starting from the resting expiratory level.
The inspiratory capacity is the sum of: TV and IRV.

The highest value is considered for VC, obtained after 3 determinations, representing the actual value of the patient (in
liter or ml). Due to the high individual variability, the ratio between the actual value and ideal value is calculated. The
ideal value is a theoretical value calculated using regression formulas, based on race, gender, age and height, from
normal subjects.
A decreased VC usually means restrictive syndrome, except obstructive syndromes with "trapped" air, when VC
decreases due to increased residual volume, and not due to decreased total lung capacity.

Functional residual capacity (FRC), residual volume (RV) and total lung capacity (TLC) assessment require more
complex investigations, considering a volume of air that can not be expelled from the lungs even after maximal
expiration (RV), included in FRC and TLC.

Functional residual capacity (FRC) is the volume of air contained in the lungs at the end of a normal expiration, when
all respiratory muscles are relaxed. Normal values: 80-120% of ideal FRC.
Residual volume (RV) is the volume of air that can not be expelled from the lungs, even after maximal expiratory effort.
RV = FRC – ERV. Normal values: 50-150% of ideal RV.
The total lung capacity (TLC) is the volume of air contained by the lungs at the end of a maximum inspiration; it can be
calculated as follows: TLC = RV + VC. Normal values: 80-120% of ideal TLC.

FRC is assessed by several methods, the most common are: helium dilution method and pletismography.
The helium dilution technique: TLC is measured by connecting the lungs to a reservoir containing a known amount of non-absorbable gas:
helium. If the concentration of the gas in the reservoir is known at the start of the test and is measured after equilibration of the gas, when the
patient has breathed in and out of the reservoir, the dilution of the gas will reflect the TLC.
Plethysmography measures the entire volume of air in the lungs, including spaces excluded from ventilation and hypoventilated territories. The
method is based on the Boyleʼs law (P X V = constant). The patient is closed in a cabin and breathes through a mouthpiece provided with a flow
switch. At the end of a normal exhalation, the switch is activated. During inspiration, no air can enter the lungs, and the air in the lungs is
decompressed and the cabin is compressed due to expansion of the rib cage. Pressure changes occuring in the lungs and in the cabin are
inversely proportional to the volumes of gas. Knowing that the cabin volume is 600 l and measuring both pressure variations (in the lungs and
cabin), we can calculate the gas volume in the lungs.

Determination of the Forced Expiratory Volume in First Second (FEV1)

FEV1 is the maximal volume of air exhaled in the first second of a forced expiration from a position of full
inspiration, expressed in liters (Fig. 2).
The severity of any spirometric abnormality based on the forced expiratory volume in one second (FEV1) is according to
the value of FEV1.
The FEV1 is usually expressed as a percentage of the FVC, i.e. the FEV1/FVC ratio and provides an excellent measure
of airflow limitation. Normal values: FEV1/FVC > 70 – 85%

FEV1 is the maximal volume of air exhaled in the first second of a forced expiration from a position of full inspiration.
FEV1/FVC ratio provides an excellent measure of airflow limitation. Normal values: FEV1/FVC > 70 – 85%.

Pathological changes:
The FEV1/FVC ratio is a good parameter for differentiating the obstructive ventilatory impairments from the
restrictive ones:
- In restrictive lung disease, the FEV1 and the FVC are reduced in the same proportion and the ratio FEV1/FVC
remains normal or may even increase (because of the enhanced elastic recoil).
- In obstructive lung disease (airflow limitation), FEV1 falls more than FVC, and the ratio FEV1/FVC is reduced.

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 Figure 2. Forced expiratory volume in the first second (FEV1)

Maximal voluntary ventilation (MVV)

The MVV is the maximum volume of air a subject can breathe over a specified period of time (12 s for normal
subjects). It is expressed in liter/min. If FEV1 is available, then MVV has little additional contribution to make in a clinical
setting. However, it may be useful in those conditions where ventilatory capacity may be impaired by mechanisms that
are different from those affecting FEV1.
Test procedure:
The subject is tested in the sitting position wearing a nose clip. After the subject makes an airtight seal around the
mouthpiece, at least three resting tidal breaths should be obtained, followed by rapid breathing. The tongue and teeth
must be positioned in order to not obstruct the airflow. The subject is instructed to breathe as deeply and rapidly as
possible. The MVV should be calculated from the sum of all individual exhalations. The MVV generally parallels the
FEV1 and can be used to estimate maximal pulmonary performance and the effort capacity.
Pathological changes:
A low MVV can occur in obstructive diseases, but is more common in restrictive conditions. If the MVV is low but FEV1
and FVC are normal, poor patient effort, a neuromuscular disorder, or major airway lesion must be considered.

Types of ventilator dysfunctions:

Considering VC, FEV1 and FEV1/FVC, may enable diagnosis of ventilator dysfunction (table 1).

Table 1. Types of ventilatory dysfunctions

Type of ventilatory Characteristics Causes

dysfunction
RESTRICTIVE ventilatory VC: decreased Parenchymal: pneumoconiosis, pulmonary
dysfunction FEV1 N/decreased at important decreases tuberculosis, lung resection, pneumonia,
of VC interstitial fibrotic lung disease (RV
FEV1/FVC: normal or increased decreased)
TLC: decreased Extraparenchymal: pleural diseases,
kyphoscoliosis, obesity, paralysis of the
diaphragm, muscular dystrophy (RV
increased)
OBSTRUCTIVE ventilatory FEV1: decreased Bronchial asthma, COPD, cystic fibrosis,
dysfunction VC: normal or decreased in severe distal bronchial tumors, intrabronchial foreign
airways obstruction bodies
FEV1/FVC: decreased

In MIXED ventilatory dysfunctions: VC, FEV1 (< 30%) and FEV1/FVC and TLC are decreased.
Causes: pulmonary tuberculosis associated with chronic bronchitis.

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 2. Flow-volume loop
The ability to measure flow rates against volume enables a more sophisticated analysis of the site of airflow
limitation. The flow-volume loop (figure 3) can be determined using a spirometer equipped with a flow
transducer. It may be achieved after a maximal forced respiratory effort. The subject is asked to blow as
vigorously as possible.

Figure 3. Flow-volume loop

The flow-volume loop consists of an:

- expiratory part: peak exploratory flow rate (PEFR) and maximal expiratory flow rate at 50% of VC
(MAF50%).
- inspiratory part: maximal inspiratory flow rate at 50% of VC (MIF50%).

The peak exploratory flow rate (PEFR) is the maximal value reached by the airflow during expiration,
occuring at the beginning of the forced expiration (in the first 2 msec), at a pulmonary volume near the TLC.
It depends on the expiratory effort and varies markedly from one individual to another and from one
measurement to another. It correlates well with FEV1. A decrease of PEFR with more than 35% is
pathological and occurs in both obstructive and restrictive syndromes.
PEFR may be monitored ambulatory using the peakflowmeters and it is an extremely simple and cheap
test. Subjects are asked to take a full inspiration to total lung capacity and than blow out forcefully into the
peakflowmeter. The best of three tests is recorded. PEFR is best used to monitor progression of disease
and therapy. Wide diurnal variations characterize asthma. Daily variability may be calculated, as follows:

PEFRmax PEFRmin
Daily variability= 100
PEFRmax

It is normally below 10%, exceeding 15% in asthma. It increases directly with the severity of the disease: <
20% in mild asthma, 20-30% in moderate asthma and ˃ 30% in severe asthma.

The maximal expiratory flow rate at 50% of VC (MAF50%) is the expiratory flow rate measured when
50% of the VC was exhaled during a forced expiration. It does not depend on the expiratory effort, but on
the distal airway permeability. A decrease with more than 35% is due to a distal airways obstructive
syndrome, occuring earlier than a decrease of FEV1.
The maximal inspiratory flow rate at 50% of VC (MIF50%) corresponds to MEF50% for forced
inspiration. It depends on the inspiratory effort and exhibits greater values than MEF50% because during

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inspiration there is no dynamic airway compression. Its decrease with more than 35% is significant for
superior airways obstruction.

Not only the values of flow rates are important, but also the shape of the loop:
- narrowed in restrictive diseases: significantly decreased pulmonary volumes; relatively normal flow
rates (figure 4, 5)
- flattened in obstructions of the upper airways (tracheal stenosis): rectangular configuration of the
flow-volume loop; fixed obstruction limits flow equally during inspiration and expiration (figure 7)
- in typical distal airways obstructive diseases due to COPD, asthma, cystic fibrosis all maximal
instantaneous flow rates are decreased (PEFR, MEF50%, MIF50%) (figure 6).

Figure 4. Parenchymal restrictiv syndrome Figure 5. Extraparenchimal restrictive syndrome

(decreased RV) (increased RV)

Figure 6. Typical obstructive syndrome Figure 7. Central obstructive syndrome

CLINICAL CASES: MCQs:

1. Interpret the following ventilometric 1. A RV of 170%:
results: A. Is within normal values
VC = 88%, B. Occurs in parenchymal restrictive
FEV1 = 70%, syndromes
FEV1/VC = 66% C. May occur in pulmonary emphysema
RV = 201%, D. Is decreased
TLC = 128% E. Occurs in extraparenchymal restrictive
syndromes
2. Interpret:
VC = 61%, 2. Which of the following cause
FEV1 = 63%, obstructive ventilatory
FEV1/VC = 88%, dysfunction?
RV = 98%, A. Asthma
TLC = 64% B. Intrabronchial foreign bodies
C. Pulmonary tuberculosis

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D. Pulmonary emphysema
E. Obesity

3. Which of the following cause

restrictive ventilatory dysfunction?
A. Muscular dystrophies
B. Kyphoscoliosis
C. COPD
D. Intrabronchial foreign bodies
E. Obesity.

4. A peak expiratory flow rate:

A. Below 10% is normal
B. Of 60% occurs in obstructive
respiratory diseases
C. Of 50% is normal
D. Below 80% occurs in restrictive
pulmonary disease
E. Correlates well with the FEV1.