Pulmonary function tests

PFTs
objectives:

• objectives:
• Define the main classes of pulmonary function tests and their
relevant importance
• Comprehend and differentiate between lung volume tests and their
interpretation
• Diffusion test and clinical relevance
• Tests for respiratory muscles and their implication
 Pulmonary function tests
PFTs Lab equipment

Pulmonary Function Tests (PFTs)

➢Are a group of noninvasive tests that measure lung function.
➢ PFTs , help support a diagnosis by supplementing detailed history, physical exam
findings, and laboratory results.
➢To interpret and use PFT results, an understanding of lung mechanics is necessary.
➢A fully equipped pulmonary function lab must have the following equipment:
1. Spirometer
2. Body plysethmogaphy
3. Diffusion system
4. ABG analyser
5. Treadmill or bicycle for exercise testing
 Pulmonary function tests
Normal values:

➢PFT become more useful when we are able to predict the normal range for every
patient or subject accurately
➢Thus, any value that deviate from predicted can help to make a judgment about
the severity of the disease.
➢Normal predicted values depend on:
Height and weight, Gender, Age , race
➢PFTs can de classified as :
I. Lung volume tests
II. Pulmonary diffusion tests
III. Respiratory muscle strength tests
 Pulmonary function tests
I. Lung volume tests (A.spirometry)

A. Spirometry
The spirometer is the primary instrument used in PFTs
• Measures airflow and estimates lung size. The tests require
the patient to fully inhale and exhale forcefully into a
mouthpiece connected to a spirometer.
• The spirometer records the rate of exhalation and the amount
of air exhaled.
• More specifically, spirometry measures forced vital capacity
(FVC),forced expiratory volume (FEV) and flow volume
loop.
• Spirometry helps evaluate the severity of a large range of analyzing forced vital capacity FVC and
lung diseases. flow-volume loop using Spirometry
The spirometer is connected to a
• All spirometers should be calibrated on daily basis to ensure spirograph and the tracing is called
accurate results. spirogram
 I. Static Lung volume tests (A.spirometry)
▪ Measure the amount of air that can
be held in the lungs.
▪ Are important for lung mechanics
and work of breathing
• Tidal volume
• Inspiratory reserve volume
• Expiratory reserve volume
• Inspiratory capacity
• Functional residual capacity
• Vital capacity
• Residual volume
• Total lung capacity
Clinical testing for
pulmonary functions

• The spirometer measures air flow during inspiration

and expiration and calculates lung volume and
capacities
• Pulmonary function tests are often used to diagnose
abnormalities in lung function and to assess the
progression of lung disease.
• They can distinguish the two major types of
pulmonary pathophysiologic processes: obstructive
lung diseases and restrictive lung diseases.
• In obstructive pulmonary diseases, an elevation in
RV/TLC ratio is secondary to an increase in RV out of
proportion to any increase in TLC.
• In restrictive lung diseases, the elevation in the
RV/TLC ratio is caused by a decrease in TLC.
 I. Dynamic Lung volume tests (A.spirometry) :
Dynamic mechanics is the study of respiratory system in motion, it is the study of the properties of a lung when its
volume is changing with time: (dynamic lung volumes is the study of volume changes with respect to time).
1-Vital capacity VC:
• After the person has taken the deepest possible breath, he or she is asked to exhale maximally (rapidly) and
forcefully
forced VC “ FVC”
(VC=TV+IRV+ERV)
FVC is the most common way for VC testing.
Proper coaching is required to get best results.

If the patient is asked to slowly exhale this is slow VC “SVC”

Interpretation:
Both restrictive and obstructive lung diseases reduce FVC
Restrictive lung diseases: is the decrease in the total volume the lungs are able to hold (lung fibrosis, sarcoidosis)
Obstructive lung diseases: a group of inflammatory diseases that result in obstruction of air flow and increased airway
resistance (chronic bronchitis ,COPD, asthma).
The VC measured by forced exhalation (FVC )may be less then Slow VC (SVC) and it is the most commonly used test.
SVC helps determine if there is airway obstruction because slow exhalation reduces airway trapping and obstruction.
 I. Dynamic Lung volume tests (A.spirometry)

Speed of airflow:
➢ To meet the metabolic needs, gas exchange depends on the speed at which fresh gas is brought to the
alveoli and the speed at which CO2 is washed from alveoli.
➢ Two major factors determine the speed at which gas flow :
A. Pattern of flow:
• turbulent flow occurs in the trachea even during quiet breathing, distal to trachea velocity is reduced
and flow is laminar even with maximum ventilation.
B. Resistance to air flow:
• Under normal respiratory conditions, air flows through the respiratory passageways so easily that less
than 1 cm H2O pressure gradient from the alveoli to the atmosphere is sufficient to cause enough
airflow for quiet breathing.
• The greatest amount of resistance to airflow occurs in some of the larger bronchioles and bronchi
(diameter greater than 2mm),(The reason for this high resistance is that there are relatively few of these larger bronchi in
comparison with the approximately 65,000 parallel terminal bronchioles, through each of which only a minute amount of air
must pass)

• In some disease conditions, the smaller bronchioles play a greater role in determining airflow
resistance because of their small size and because they are easily occluded by : muscle contraction in
their walls; edema in the walls; or mucus collecting in the lumens of the bronchioles
 I. Dynamic Lung volume tests (A.spirometry)

Resistance to airflow:
➢tests for airway resistance ( e.g.plethysmography ) may not be adequate for detecting small
airway obstruction ( the small airways contribute so little to total lung resistance which
occurs in airways with diameters greater than 2 mm).
➢Alternatively, we use FVC and other tests to help estimate resistance to air flow in small
airways
➢One of the most important factors that affect airway resistance (caliber of airways) is lung
volume:
• Increasing lung volume increases the caliber of the airways because it creates a
positive trans- airway (distending ) pressure.
• with decreasing lung volume (expiration), resistance to airflow increases.
• This effect becomes more exaggerated when there is an abnormal narrowing of small
airways.
 I. Dynamic Lung volume tests (A.spirometry) :

Forced vital capacity and Expiratory Flow Volume

The patient is comfortably seated, then breathes maximally (deep
inspiration) then exhales as rapid and as far as possible till the RV.
• Recording starts from the beginning of exhalation.
• The expired volume is plotted against time and expiratory flow
is recorded
• The expiratory FVC provides information about lung elasticity and
bronchial constriction.
• Small bronchi are held open by elastic tissue of the lungs
• Forced exhalation increases intrathoracic pressure and makes
airways collapse thus limiting flow during expiration.
• Expiratory flow is measured during the 1st,2nd and 3rd seconds of
expiration:
• Forced expiratory volume 1st second FEV1 most common
• Forced expiratory volume 2nd second FEV2
• Forced expiratory volume 3rd second FEV3
 I. Dynamic Lung volume tests (A.spirometry) :

Forced vital capacity FVC curves and forced

Expiratory volume FEV1
FEV1 :
• In normal individuals, 70% to 85% (depending on age) of the FVC
can be exhaled in the first second.
• FEV1/FVC > 70% is normal
• FEV1/FVC <70% suggests difficulty exhaling because of
obstruction and is a hallmark of obstructive pulmonary disease
Interpretation of the test:
Normal:
FEV1/FVC = 2.8 /4 = 70%
Obstructive lung diseases:
FEV1/FVC = 1 /3 = 30%
Restrictive lung diseases:
FEV1/ FVC = 1.5/2.8= 50 %

From Wilkins et al, Egan’s Fundamentals of

respiratory care,ed9
 Forced vital capacity curves and forced expiratory volume FEV 1
Interpretation of the test:

FVC is reduced in :
thoracic cage diseases and injuries
Pneumothorax, Fibrosis of pleura, Heart failure,
COPD
FEV1/FVC helps distinguish restrictive from
obstructive lung diseases
 I. Dynamic Lung volume tests (A. spirometry)

Expiratory flow rate and expiratory flow

volumes:
Are another important clinical tools for evaluating and
monitoring respiratory diseases.
➢ Expiratory flow rate is determined by FVC
➢ Expiratory volume is determined by flow volume loop

▪ Expiratory flow rate (FEF25-75).

The average flow rate over the middle section of the FVC
(Volume of expired air during this phase of expiration / time)
It is not reproducible as FEV1 This expiratory flow rate has
Normal range 65-100% several names, including
MMEF (midmaximal
Can be reduced in COPD when FEV1 still normal. expiratory flow) ;
FEF25-75 (forced expiratory
flow from 25%–75% of VC)
 I. Dynamic Lung volume tests (A.spirometry)

Expiratory flow rates (FEF25-75), measured from FVC:

Normally FEF25-75 is completed in 1st sec

To get the value, we divide FEF25-75/time in sec

This expiratory flow rate has

several names, including
MMEF (midmaximal
expiratory flow)
FEF25-75 (forced expiratory
flow from 25%–75% of VC)
 I. Lung volume tests (A. spirometry) :

2. Flow volume curves (Flow volume loops):

Another way of measuring lung function (compliance and airway
resistance) clinically is the flow-volume curve or loop.

A flow-volume curve or loop is created by displaying the instantaneous

flow rate during a forced expiration as a function of the volume of gas.

It gives a better interpretations for airway resistance, since airways are

situated inside the thoracic pump ,they are affected by volume changes
of the pump system(lung and chest wall).

This instantaneous flow rate can be displayed both during exhalation

(expiratory flow-volume curve) and during inspiration (inspiratory flow-
volume curve)
Expiratory flow rates are displayed above the horizontal line
inspiratory flow rates are displayed below the horizontal line
 I. Lung volume tests (A. spirometery) :
2. Flow volume curves (Flow volume loops):
The maximum inspiratory flow is the same or slightly greater than the
maximum expiratory flow.

The maximum inspiratory flow is determined by:

1. the force generated by the inspiratory muscles (decreases as lung
volume increases ) .
2. The recoil pressure of the lung ( increases as the lung volume
increases) This opposes the force generated by the inspiratory muscles
and reduces maximum inspiratory flow (especially late in inspiration).
3. Airway resistance ( decreases with increasing lung volume as the
airway caliber increases).

The net effect of these three factors causes maximal inspiratory flow to
occur about halfway between TLC and RV
 I. Lung volume tests (A. spirometry) :
2. Flow volume curves (Flow volume loops):
The maximum expiratory flow
Normally,maximal flow with expiration occurs early (in the first 20% VC )
and is effort dependent

flow rates decrease progressively toward RV even with increasing effort

Expiratory flow rates at low lung volumes are said to be effort

independent, No amount of additional effort can increase the flow rate
beyond this limit

This is known as expiratory flow limitation :

with modest effort, maximal expiratory flow is achieved, there after, no
amount of effort will increase the flow rates as lung volume decreases.

.
 Expiratory flow volume loop and flow limitation:
The airways and alveoli are surrounded by the pleural space and
the chest wall.
Flow limitation occurs when the airways, which are intrinsically
floppy distensible tubes, become compressed.
The airways become compressed when the pressure outside the
airway exceeds the pressure inside the airway.
This occurs for three reasons:
1- pressure loss (frictional resistance) during expiration
2- The gas velocity increases (as air reaches trachea) further
decreases the pressure as lung volume decreases,
3- The elastic recoil pressure decreases
Thus, as air moves out of the lung, the driving pressure for
expiratory gas flow decreases.
In addition, the mechanical tethering that holds the airways open
at high lung volumes diminishes as lung volume decreases.
There is a point between the alveoli and the mouth at which the
pressure inside the airways equals the pressure that surrounds
the airways. This point is called the equal pressure point.
 flow limitation:
The airways are shown as tapered tubes because the total airway cross sectional
area decreases from the alveoli to the trachea (v=1/ total cross sectional area)
P L = PA − P pl
PA = P L + Ppl
➢ With forced expiration: fig B (TLC-1L)
Ppl=60
PL= 90-60=30
PA= 30+60=90
As air moves along airways:
Airway pressure becomes less than alveolar pressure
P airway =70 Ppl = 60 Trans airway=70-60=10
➢ With forced expiration: fig C (TLC-2L)
Ppl=60
PL = 70-60=10
PA= 10+60=70
As air moves along airways:
Airway pressure drops more
P airway= 60 Ppl= 60 Trans airway= 60-60 = 0 zero flow “equal pressure point”
Airflow is now independent of the total driving pressure and the expiratory flow is
effort independent
 Pressures in the respiratory system:
• Pressures in the respiratory system are referred to atmospheric pressure.
1. Intra-alveolar pressure: pressure of air inside alveoli
2. Intrapleural pressure : pressure inside pleural cavity is normally slight sub atmospheric (negative P).
This negative pressure is created by the inward elastic recoil of the lung, that is balanced by the outward recoil of
the chest wall. The continuous suction of fluid by lymphatics also helps maintaining this negative intrapleural pressure.
3. The transpulmonary (or translung) pressure (PL),
Is the pressure difference between the alveolar pressure [PA]) and the pressure
surrounding the lung (pleural pressure [Ppl])
P L = PA − P pl
4. The transmural pressure across the chest wall (Pw) is the difference between pleural (inside) pressure (Ppl) and the pressure
surrounding the chest wall (Pb) (atmospheric P)
Pw = Ppl - Pb
5. The transmural pressure across the respiratory system (Prs) is the sum of the pressure across the lung and the pressure across
the chest wall:
Prs = PL + Pw

= (PA − P pl ) + (Ppl - Pb)

 Translung pressures =
elastic recoil pressure:
• Pressures across surfaces (transmural) such
as across the lungs or across chest wall are
defined as the difference between the
pressure inside and the pressure outside
the surface.
• Relationship between transpulmonary
pressure (PL) and the pleural (Ppl), alveolar
(PA), and elastic recoil (Pel) pressures of the
lung are as follows:
• Alveolar pressure is the sum of pleural
pressure and elastic recoil pressure.

• Transpulmonary pressure is the difference

between alveolar pressure and pleural
pressure
• P L = PA - P pl
• P L= (P el + Ppl )- Ppl Transpulmonary pressure equals the elastic recoil P
• PL = Pel of the lungs
 I. Lung volume tests (A. spirometry) :
2. Flow volume curves (Flow volume loops): Interpretation
In restrictive lung diseases:
▪ The lungs have both reduced (TLC) and reduced (RV).
▪ Furthermore, because the lung cannot expand to a normal maximum
volume (VC), the maximal expiratory flow cannot rise
as normal.
▪ The flow envelope is flattened but if flow rate is compared to lung
volume it is high
Restrictive lung diseases include : fibrosis of lung, such as tuberculosis
and sarcoidosis ; chest cage abnormalities as kyphosis, scoliosis, and
fibrotic pleurisy.

In obstructive airway diseases:

It is usually much more difficult to expire than to inspire because the
closing tendency of the airways is greatly increased by the extra positive
pressure required in the chest to cause expiration.
In chronic bronchitis and emphysema max. expiration begins at high
lung volumes (early in the curve) and flow rates are much lower than
normal
 I. Lung volume tests (A. spirometry) :
2. Flow volume curves (Flow volume loops): interpretation
The equal pressure point is not fixed , first at the trachea, then,
expiration proceeds, the equal pressure point becomes in the smaller
airways.
➢ Therefore, late , in forced expiration, resistance (due to compression)
is determined by small airways.
So early in COPD small airway obstruction can be detected by
flow- volume loop using
FEF 50-75 which is the flow rate at 50 to 70% of VC (blue arrow).

➢ The test also detects upper airway obstruction.

• Normal (left)
• COPD (right) : showing
characteristic
• The maximum expiration begins
and ends at high lung volumes
• Flow rates are much lower than
normal
• The curve may have scooped out
appearance .
 I. Lung volume tests ( B. Body plethysmography)

B. Body plethysmography:
• This test is the gold standard for lung volume measurement.
• The body plethysmography, requires sophisticated and expensive
equipment
• All gases in the lung can be measured
• It takes advantage od Boyle’s law : (the product of pressure and
volume in the chest should be the same as the product of volume and
pressure in the box).
So we use the following formula:
P1 X V1= P2 X V2
P1 gas pressure in the lungs
P2 gas pressure in the box
V1 unknown volume in the lung
V2 known volume in lung and box
 Measurement of RV and TLC:
The body plethysmography
• The subject sits in a totally closed box with known
gas volume.
• According to Robert Boyle’s gas law: pressure
multiplied by volume is constant (at a constant
temperature)
• The patient breathes through a mouthpiece that is
connected to a flow sensor (pneumotach). The
patient then makes a panting respiratory effort
against a closed mouthpiece, lung p is recorded.
• During the expiratory phase of the maneuver, the
gas in the lung becomes compressed, lung volume
decreases, and the air pressure inside the box falls
because the gas volume in the box increases. (as
the walls are rigid and there is a certain volume
shared by the chest and the box).
• As the body box is sealed and has rigid walls,
ΔV is volume volume changes experiences the same, mirror
change In the box image-like shift volume as the lung.
Measurement of RV and TLC: The body
plethysmography
With exhalation:
Intrathoracic volume V decreases volume of the box increases by a certain amount : Δ V
that is mirroring the lung expired volume.
Airway Pressure is recorded before P1 and after exhalation P2
Lung gas volume is recorded before V and after exhalation ( V - Δ V)
P1 X V = P2 X ( V - Δ V)
P1X FRC = P2 X ( FRC – expiratory reserve volume) this method is not reproducible.

The FRC can be estimated during tidal breathing :

P1XV = P2X ( V + Δ V)
P1X FRC = P2 X ( FRC + TV)
 I. Lung volumes (gas dilution methods) :

Measurement of RV and
TLC: Helium dilution method
• RV and TLC can be measured in two ways: by helium
dilution and by body plethysmography.
• The helium dilution technique is the older and simpler
method, but it is often less accurate
• Body plethysmography, is more accurate but requires
sophisticated and expensive equipment
• The FRC measured by both methods is not the same:
• helium dilution method measures only gas in lungs that
communicates with airways.
• The FRC measured by plethysmography is the total volume
of gas in the lungs at the end of a normal exhalation.
• If a significant amount of gas is trapped in the lungs
(because of premature airway closure) the FRC
determined by plethysmography is considerably higher
than that determined by helium dilution.
 Pulmonary function tests
II. Pulmonary diffusion capacity
1-Pulmonary diffusion capacity ”diffusing capacity of the lung for carbon monoxide “DLCO”
single breath “DLCO-SB”
It is commonly measured by having the patient inhale 0.4% CO (mixed with a soluble tracer eg Helium)
• The patients are initially asked to take normal resting breaths ; this is followed by full exhalation
up to residual volume (RV). The patient is then asked to rapidly inhale the test gas up to vital
capacity (VC). The test gas contains: 0.3% CO0.3% tracer gas (helium, methane, or neon)21%
oxygen, balance nitrogen
• The patient is then asked to hold his breath for 10 seconds at total lung capacity (TLC).
• Subsequently, the patient exhales out completely, and exhaled gas is collected for analysis
• The collected gas is analyzed for CO and tracer concentrations
➢ It is affected by factors that affect diffusion across respiratory membrane ,specially, surface area
➢ It is affected by ventilation perfusion mismatch (low V/Q) due to reduction of effective surface area.
➢ It is reduced by reduced Hgb ( anemia) and increased in hemosiderosis
➢ This test is essential in diagnosing emphysema and interstitial lung disease, especially after reduced vital
capacity measured by spirometry
 Pulmonary function tests
II. Pulmonary diffusion capacity

• “DLCO”
• CO rapidly binds to Hgb, so does not generate
appreciable partial P. in plasma.
• As a result, blood flow does not limit the rate of CO
diffusion
• When alveolar capillary membrane is abnormal, the
rate of CO diffusion is reduced
• This phenomenon is called diffusion limited, which
means that the structural of the alveolar membrane
alone limits the rate of diffusion.
 diffusion of O2
Under normal resting conditions equilibration occurs in the During exercise or stress the transient time can be reduced
first 0.25sec of transient time of blood across If transient time=0.25 sec ,equilibration occurs
alveolocapillary membrane. transport of O2 But if transient time becomes shorter than 0.25 sec, transport of O2
is perfusion limited. is then diffusion limited
 diffusion of O2

➢When there is thickening of the alveolar

membrane ,O2 equilibrium will not occur
if the transient time of blood is reduced.
➢O2 therefore will be diffusion limited.
➢This occurs during exercise.
➢Exercise testing can be part of pulmonary
function tests and can detect diffusion
abnormalities

➢ PO2 in pulmonary venous

blood=60mmHg
 II. Pulmonary diffusion capacity

Clinical conditions known as diffusion limited.

 Pulmonary function tests
III. Respiratory muscle strength tests
➢ maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP).
• Both can be measured quickly in a noninvasive fashion.
• MIP indicates the strength of inspiratory muscles like the diaphragm. The MEP measures the
strength of expiratory muscles like the abdominal muscles.
• Measurements are taken by maximal inhalation and exhalation through a mouthpiece while
wearing nose clips.
➢ Maximum voluntary ventilation MVV:
• Measurement requires patient to breath maximally ,and rapidly for 12 to 15 sec .
• The total exhaled is extrapolated to obtain max. ventilation that would be achieved if the patient
continued for 1 min.
• The test reflects the status of respiratory muscles, compliance and airway resistance
• It also assesses patient motivation.