Iranian Society of Pulmonology

Pulmonary Function Tests

Whole-body plethysmography
basics

Hans-Juergen Smith, Germany

Sr. Product Manager Pneumonology
Ahvaz – Iran
16th February
Limits of spirometry

c Forced breathing is UNEQUAL to tidal breathing

c Flow limitation is UNEQUAL to obstruction
c Degree of obstruction?
c Small airways are not safely differentiated
c Superimposing effects, dominance of central airways
c Influence of the test itself
c Deep inspiration (broncho protection, dilatation)
c Functional and/or fixed conditions of the upper
airways
c Pain, cooperation, instruction
Degree of severity? Character of disease?
Indications for body plethysmography

c Assessment of resting conditions

c Little co-operation (pediatrics, geriatrics, occupational med….)
cGrading and differentiation
c Objectivation of limitation (stage of disease)
c Differentiation between obstruction and restriction
c Distribution of obstruction (extra thoracic, central, peripheral)
c Bronchial hyperresponsiveness
c Degree of reversibility
c Challenge testing
c Trend reports
c Excellent intra-individual reproducibility CV% < 10%
c Prognosis, Expert reports
Weibel: Morphometry of the human lung

Genera- Cross sectional Resistance

tion area [cm²] [kPa/(L/s)]

0.05
Larynx
2.5
Trachea Central
0.05
Bronchi airways
2.0
R ~ 80%
8-10

5.0
Bronchioles 0.02
17
1.8 x 10²
Peripheral
9.4 x 10² airways
Alveolar Ducts 5.8 x 10³
R < 20%
Alveoli 24 56 000 000

Weibel, Morphometry of the Human Lung, Springer 1963

Whole-body plethysmography

- Methodology
- Clinical interpretation
- Resistance/volume graphs
- Pre-post measurements
- Summary
Box calibration

Separated calibration
c Time constant (Tau)
c Shift volume

Setting (Accepted by
application as well)
c Box volume setting
c 830 L standard
c 1350 L
wheelchair
 Calibration of box signals V‘ and Vbox
Flow [L.s-1]
Pneumotachograph pressure signal
calibrated in flow-units [L.s-1]

Volumen
P-Sensor [L]

Box pressure signal

calibrated in
Volume shift [mL] Shift volume [mL]
Pump +25
50 mL P-Sensor
Time [s]
-25

Compensation chamber
 Constant-volume-box principle

1. Test phase (door closed)

Sinusoidal DPm
sRaw-measurements
pump V‘

Compen- 2. Test phase (door closed)

Raw
Shutter sation -Shutter closed-
chamber a) FRCpleth-determination
Raw
Controlled b) Linked VCmax
leakage DPA
DP
DVL 3. Test phase (door opened)
Forced spirometry
DV
General recommendations

Patient should be measured well-balanced

and free of stress!

c Sitting in upright position

c Head in neutral position or slight extension
c Nose closed by a nose clip
c Lips firmly and tightly closed around
mouthpiece / filter!
c Instructed regarding shutter manoeuvre,
linked manoeuvre and forced spirometry
1. Tidal breathing: sRaw-loop

V‘ [L.s-1] Parameters
V‘ 2
Flow sReff
sRtot
1
Raw

0
Raw
-40 -20 0 20 40
DVpleth
Volume shift -1
TGV
-2 Vpleth [mL]
DVL
The loop of specific resistance
incorporates resistive and volume
determined components, not
differentiated.
Specific airways resistance (sRaw)

Test sequence (assistant):

cBox door firmly closed!
cAutomated loop compensation activated
cInstruct spontaneous breathing without preconditions
cWait until patient is adapted to the unit – reproducible loops
after 3 to 5 breathing cycles
cLoops can be stored as soon as they are reproducible
cLow variation of approximation line (sRaw) and small loop
area
cIn case of small specific resistance values (steep loops), instruct
slight hyperventilation with BF 20-25 min-1
Quality control of breathing loops

Quality control:
c Wait for regularity of compensated loops as well as BF and VT.
c Regularity of volume trace – FRC stability, lowest WOB.

b)
a) c)

Valid: Artefacts:
Minimal 3 better 5 loops should be a) Pressure loss
reproducible! b) Over- / c) No compensation
 Summary - breathing loop

Specific resistance (sRaw) incorporates (Raw, TGV)

2 Flow [L.s-1]
sReff
c Without volume measurement! Parameters
1
c Proportional to Raw and TGV
c No resistance loop! sRtot
0
-40 -20 0 20 40
c Low variability; primary -1
measurement
-2 Shift volume [mL]

Compression / decompression measured as volume shift.

c Clear relationship to flow.
 Differential diagnostics via sRaw- loop
a) Angle (Clockwise)
c Increased airways resistance Raw and/or increased lung volume TGV

Flow V‘ [L.s-1]

sReff
Approximation

TGV Reff
Shift volume [mL]

b) Degree of opening, separately for in- and expiration

K1 closed, steep c Normal lung function
K2 not or little opened c Central obstruction
clockwise turned
K3 Golf club c Peripheral end-expiratory inhomogeneity
K4 V-shape c Elevated diafragm and/or end-expiratory „closing“
K5 Markable S-shape c Extra troracic stenosis
2. Shutter: Determination of FRCpleth

Pm [kPa] Parameter
Pm
Occlusion pressure 3 FRCpleth
2
Raw
1

Raw 0
-40 -20 0 20 40
DVpleth -1
Shift volume
-2
FRCpleth
-3 DVpleth [mL]
DVL

Determination of intrathoracic gas volume

on the level of FRC
Intra-thoracic gas volume FRCpleth

Test sequence (assistant):

c After activation of the FRC-measurement, the shutter is
automatically closed at the beginning of the following
inspiration (FRC-, ITGV-level)
c Patient should continue normal breathing, without
additional effort against the shutter
c Shutter should not be „blown up“ or „soaked-up“ by the
patient
c Lips must be firmly closed at the whole manoeuvre
c Record at least 2 shutter manoeuvres which were not
influenced by a deep inspiration, as the deep inspiration
can alter the FRC as well as the sRaw
Intra-thoracic gas volume, FRCpleth
Quality control:
c Positive & negative pressure elongation
(> 1kPa) must be recorded, otherwise the FRC is
incorrect, as the static pressure cannot be eliminated
c At least 2 successive volume measurements should be
comparable in their values (difference < 7%)
FRC reproducibility Artefacts
 Settings of the Shutter

Opening of the shutter which was closed at

the end of expiration (FRC, ITGV)

Depending on the patient group:

c Children t > 3 s resp., Pcumulative > 4 kPa

c Adults t > 4 – 5 s resp., Pcumulative > 6 kPa

In the manoeuvre against the shutter, the patient

should achieve a minimum alternating pressure of
+/- 1 kPa.
FRC linked with VCmax

TLC = RV + VCmax

PEF
sRaw (Raw) IC FEV1

VT VC IN FVC
FEF xx

V [L] V [L]
ERV FEV1
t [s] V‘ [L.s-1]

FRCpleth RV TLC RV = FRCpleth - ERV

RV%TLC FEV1%FVC
Quality assurance related to FRCpleth
1. Calculation of Raw
Raw = sRaw / FRCpleth, Gaw= 1/Raw
2a. Recommended determination of RV and TLC started
with ERV effort
RV = FRCpleth – ERV, TLC = RV + VCmax
= FRCpleth – ERV + VCmax

2b. Determination of RV and TLC started with IC effort

TLC = FRCpleth + IC, RV = TLC - VCmax
= FRCpleth + IC - VCmax

Note: Any incorrect determination of FRCpleth will lead to wrongly

calculated Raw, RV and TLC!
Most of the clinical interpretation concepts are not applicable then.

However, sRaw and sGaw are still available for interpretation.

Recommended test sequence
Combination with spirometry
2
3

FEV1
1 2

0
1 FEV1
0
-40 -20 0 20 40 -40 -20 0 20 40
-1
-1
-2
IRV

-2 -3

IRV FVC
IC
VT

VT

ERV
ERV

TLC
Adaptation 1. FRCpleth
5 x sRaw 2. FRCpleth
RV

RV

2-5 x Flow-Volume
10 s time window
Linked manoeuvre – by ATS/ERS
Problem is influence of deep, maximal inspiration (Dilatation!)

Recommendation:
ERV followed by IVC

alternative:
IC followed by EVC

SERIES ‘‘ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING’’

Edited by V. Brusasco, R. Crapo and G. Viegi
Number 3 in this Series Standardisation of the measurement of lung volumes
J. Wanger, J.L. Clausen, A. Coates, O.F. Pedersen, V. Brusasco, F. Burgos, R. Casaburi, R. Crapo, P.
Enright, C.P.M. van der Grinten, P. Gustafsson, J. Hankinson, R. Jensen, D. Johnson, N. MacIntyre, R.
McKay, M.R. Miller,
D. Navajas, R. Pellegrino and G. Viegi; Eur Respir J 2005; 26: 511–522
Result mode

c Best = black
c Original curve color
on top of windows
Quality control
Recommendation
c DO NOT EDIT !
c Only de-selection /
rejection of artifacts !
c Instead!:
c Repeat manoeuvres!

c Highly efficient
algorithms provide
low variability of the
test results at “best”
Result mode

c Best = black
c Original curve color
on top of windows
Quality control
Recommendation
c DO NOT EDIT !
c Only de-selection /
rejection of artifacts
!

c Highly efficient
algorithms provide
low variability of the
test results at “best”
Result mode

Work of breathing
WOB
c Best = black
c Original curve color
on top of windows
c Resistive WOB –
different from
compliance

R-V chart
c Only one loop
c Real resistance loop
c Average of all
accepted sRaw-
loops
Application screen menu

RV chart

Breathing loops
Any questions so far?
Whole-body plethysmography

- Methodology
- Clinical interpretation
- Resistance/volume graphs
- Pre-post measurements
- Summary
sRtot according to Ulmer
Flow V' [L/s]
2

sRtot
1 sRtot sRtot IN

0
sRtot EX

-1

sRtot
-2
Shift volume Vpleth [mL] Rtot = sRtot / (FRCpleth+VT/2)

For the determination of sRtot, the points of

maximum shift volume (DVpleth) on the specific
resistance loop, are connected by a straight line.
Specifics of sRtot (Rtot)

Advantages:
c Sensitivity down to the peripheral airways.
c Every single change of the broncho-pulmonary system is
recorded, therefore it is well suited for observation of
challenge or dilatation.

Disadvantages:
c Marginally higher intra-individual variability compared to
Reff.
c Derived from only two points (maximum shift volume) of the
specific resistance loop which causes higher risk of
methodical variability.
c Overestimation of lung periphery at high resistance values.
sReff according to Matthys
Flow V' [L/s]
2

1 sReff sReff sReff IN

-1 sReff EX
sReff
-2
Shift volume Vpleth [mL] Reff = sReff / (FRCpleth+VT/2)
The sReff value is derived from the area of work of breathing
divided by the area of the flow-volume-loop at normal
breathing.
Specifics of sReff (Reff)

Advantages:
c Especially sensitive within the central airways.
c Low variability, intra- as well as inter-individual.
c Derived from the whole area of the specific
resistance loop.

Disadvantages:
c Peripheral changes are not sufficiently sensitively
represented.
sR 0.5 Specific resistance at 0.5 L/s

Flow V' [L/s]

2

1 sR 0.5 sR 0.5 sR 0.5 IN

0.5 L/s
0

-0.5 L/s
-1

sR 0.5
-2
Shift volume Vpleth [mL] R 0.5 = sR 0.5 / (FRCpleth+VT/2)

Straight line between sRaw-values at plus and minus 0.5 L/s.

Specifics of sR 0.5 (R 0.5)

Advantages:
c High sensitivity within the central airways.
c Low variability, intra- as well as inter-individual.
c Well suited for pre- post-measurements.
c Flow-standardized.

Disadvantages:
c Peripheral changes are not sufficiently
sensitively represented.
Clinical relevance of sRaw

Relatively independent of biometrical data

1.2 – 2.0 mild
c Pathologic lungfunction: 2.0 – 4.0 moderate
sRaw > 1.2 kPa.s Adults > 4 kPa.s severe
sRaw > 1 kPa.s Children
Flow [L.s-1]

c Reversibility:
c Without -----------no change
c Partial------------- decreasing of sRaw
c Complete -------- sRaw in normal range
Shift volume [mL]

c Provocation:
PD/C +100 sRaw & > 2.0 kPa.s
PD/C -40 sGaw & < 0,5 kPa-1.s-1 sGaw = 1 / sRaw
* comparable PD/C -20 FEV1 *
Threshold/references to abnormality

c Threshold to abnormality in adults:

sReff and sRtot > 1.2 kPa.s (breathing loops)
Reff and Rtot > 0.3 kPa.s.L-1 (ECCS 83/93)

c Predicted in children according to Zapletal (< 18 years)

Reff and Rtot > 150% of predicted
cThreshold in children for specific resistance (breathing
loops)
sReff and sRtot > 1 kPa.s

Lung volume
c Predicted according to Quanjer and Zapletal
FRCpleth > 140% of predicted
Bronchial hyperresponsiveness

c Provocation:
sRaw PD/C+100sRaw & > 2,0 kPa.s
sGaw PD/C -40 sGaw & < 0,5 kPa-1.s-1
(Raw PD/C +100Raw & > 0,6 kPa.s.L-1)
(use of effective (specific) resistance/conductance recommended)
FEV1 PD/C -20FEV1

c Reversibility in comparison to basic measurement

c Without ----------------------- no change
c Partial -----------------------diminishment of Raw und FRCpleth
c Complete -------------------- Raw & FRCpleth in normal range
Differential diagnostics - provocation

Interpretation of the loop of specific resistance

c Angle of inclination of sRaw-loop (pre – post)
c Increased airway resistance Raw
c Hyperinflation

c Opening of the loop

pre post
c Without or constant
sRaw opening
> proximal obstruction
sRaw c „golf club“
> distal obstruction
FRCpleth FRCpleth
c „S-form“
> extrathoracic stenosis
 Central obstruction
Elongated sRaw-loop; clockwise inclined
c Raw > 0,3 kPa.s.L-1 (children >150% predicted)
c FRCpleth normal

2 sRtot
pred
1
Flow [L.s-1]

0 Severity code from Raw

< 0,3 kPa.s.L-1 no obstruction
-1 < 0,35 kPa.s.L-1 border
< 0,5 kPa.s.L-1 mild
Shift volume [mL] < 0,8 kPa.s.L-1 moderate
-2
> 0,8 kPa.s.L-1 severe
 Peripheral obstruction
2 Loop of sRaw gets pattern of „golf
Pred sRtot club“ in case of inhomogeneous
1
Flow [L.s-1]

airway obstruction.
0 Adults: Raw > 0,3 kPa.s.L-1
Children: Raw > 150% pred)
-1 RV, FRCpleth, TLC >>, VC <

-2 Shift volume [mL]

Hyperinflation
Occlusion pressure [kPa]

3
RV > 140% Pred
2
FRCpleth RV/TLC ~ 35% border
1 RV/TLC ~ 40% mild
0 RV/TLC ~ 50% moderate
RV/TLC ~ 60% severe
-1

-2 Pred
-3 Shift volume [mL]
Relative and absolute hyperinflation

Lung volume
RV%TLC Stage TLC% pred
TLC Normal 85-114 %
RV%TLC Mild 115-139 %
Abnormal >140
TLC TLC RV
Stage RV%TLC
Normal < 35 %
RV Borderline 36-40 %
Mild 41-50 %
increased
RV
Moderate 51-60 %
Severe > 61 %

Normal Relative Absolute

hyperinflation Sorichter S, 2002
Obstruction - restriction
c Detection of restriction by clearly diminished TLC;
FRCpleth of less relevance
c Obstructive parameters are Raw and RV respectively

Obstruction
Increase of resistance
Restriction
Raw Reduction of volumes

Flow limitation TLC

c TLC
c TLC n, c FRCpleth n,
c FRCpleth n, c RV n,
c RV
FRCpleth
c RV%TLC
TLC IRV VT ERV RV
 Combined obstructive-restrictive disease

c Raw and FEV1 define

TLC (VC) obstruction
c RV represents
TLC hyperinflation
IRV c TLC provides evidence
of restriction

VT FEV1
FRCplet FRCpleth
h

ERV
RV
RV sRaw
Extra-thoracic stenosis

Fixed and/or functional stenoses

2 provide
S-pattern of sRaw-loop

1
Flow [L.s-1]

-1

-2 Shift volume [mL]

In case of stenosis, non of the

interpretations concepts are applicable.
Clinical interpretation (Ulmer)
Bronchial Asthma

Important parameters:

c Airways resistance Rtot

c Intrathoracic gas volume RV =,
pred act

pred pre post

sRtot
c Adjusted flow/volume-loop!
Asthma – provocation report

Last Name: Identification: 1028651

First Name: 1. Basic
Date of Birth: 15.04.1924 Age: 80 Years 2. Provocation 1
Sex: female Height: 158 cm
Weight: 65 kg
3. Provocation 2
4. Dilatation

Spirometry Body plethysmography

Whole-body plethysmography

- Methodology
- Clinical interpretation
- Resistance/volume graphs
- Pre-post measurements
- Examples
Example 1 - COPD

Severe obstructive impairment

Dynamic hyperinflation
Example 2 - Combined impairment

Combined obstructive and restrictive impairment

 Example 3 - Combined impairment

Combined obstructive and restrictive impairment

Example 4 – Extra-thoracic stenosis

Extrathoracic stenosis
Obesity in combination with COPD
Chronic bronchitis
Restriction