Pulmonary Function

Robert C. Strunk, MD
Strominger Professor of Pediatrics
Washington University School of Medicine
St. Louis Children’s Hospital
Division of Allergy, Immunology, and
Pulmonary Medicine
 Disclosures
 Employment
 Washington University School of Medicine
 Research Interests
 NHLBI
 Financial Interests
 None
 Chair, Pediatric Adjudication Committee, GSK
study of safety and benefit of FP/salmeterol vs.
FP
 Spirometry

 For now, spirometry is best test to:

• Monitor asthma status
• Look for evidence of asthma
• Look for evidence of other diagnoses
Volume-Time Plot
 Forced Vital Capacity Maneuver

Airflow,
L/sec

Lung volume
 Definitions
 FVC – Forced Vital Capacity
Volume of air exhaled after a maximal inspiration to total lung capacity. This
volume is expressed in Liters
 FEV1 – Forced Expiratory Volume in 1 second
Volume of air exhaled in the first second of expiration.
This volume is expressed in Liters
 FEF 25-75%
Mean expiratory flow during the middle half of the FVC maneuver; reflects
flow through later emptying airways, not necessarily the small airways
 FEV1/FVC – Ratio (%)
Volume of air expired in the first second, expressed as a percent of FVC
 Performance of FVC maneuver

 Patient assumes the position (typically standing)

• Puts nose clip on
• Inhales maximally
• Puts mouthpiece in mouth and closes lips around mouthpiece
(open circuit)
• Exhales as hard and fast and long as possible
• Repeat instructions if necessary – effective coaching is essential
• Give simple instructions
• Repeat minimum of three times (check for repeatability)
Special Considerations in Pediatric Patients
 Ability to perform spirometry dependent on
developmental age of child, personality, and interest.
 Patients need a calm, relaxed environment and
good coaching. Patience is key.
 Be creative
 Use incentives
 Even with the best of environments and coaching, a
child may not be able to perform spirometry.
 ATS Acceptable Criteria
Within Maneuver
 Free from artifacts, such as
• Cough during the first second of exhalation
• Glottis closure that influences the measurement
• Early termination or cut-off
• Effort that is not maximal throughout
• Leak
• Obstructed mouthpiece
 Good starts
• Extrapolated volume < 5% of FVC or 0.15 L, whichever is greater
 Satisfactory exhalation
• Duration of ≥ 6 s (3 s for children < 10) or a plateau in the volume–
time curve or
• If the subject cannot or should not continue to exhale
 ATS Acceptable Criteria
Within Maneuver
 After three acceptable spirograms have been obtained, apply the
following tests
• The two largest values of FVC must be within 0.150 L of each other
• The two largest values of FEV1 must be within 0.150 L of each other
 If both of these criteria are met, the test session may be
concluded
 If both of these criteria are not met, continue testing until
• Both of the criteria are met with analysis of additional acceptable
spirograms
 or
• A total of eight tests have been performed (optional) or
• The patient/subject cannot or should not continue
 Save, as a minimum, the three satisfactory maneuvers
 Spirometry Interpretation: So what
constitutes normal?
 Normal values vary and depend on:
• Height
• Age
• Gender
• Ethnicity
 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
 Obstructive Disorders  Restrictive Disorders
• Characterized by a limitation of • Characterized by reduced lung
expiratory airflow so that volumes/decreased lung
airways cannot empty as compliance
rapidly compared to normal Examples:
(such as through narrowed • Interstitial Fibrosis
airways from bronchospasm,
inflammation, etc.) • Scoliosis
Examples: • Obesity
• Asthma • Lung Resection
• Emphysema • Neuromuscular diseases
• Cystic Fibrosis • Cystic Fibrosis
 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
 Obstructive Disorders  Restrictive Disorders
• FVC nl or↓ • FVC ↓
• FEV1 ↓ • FEV1 ↓
• FEF25-75% ↓ • FEF 25-75% nl to ↓
• FEV1/FVC ↓ • FEV1/FVC nl to ↑
• TLC nl or ↑ • TLC ↓
 Severity of any spirometric abnormalities
based on the FEV1

Degree of severity FEV1 % predicted

 Mild >70
 Moderate 60-69
 Mod severe 50-59
 Severe 35-49
 Very Severe < 35

based on ATS/ERS criteria

 Criteria Used at
Washington University PFT Lab
 FEV1 Normal (82-118% predicted)
 FVC Normal (82-118% predicted)
 TLC < 80 % predicted for restriction
 RV/TLC above 30% for air trapping

Degree of severity FEV1 % predicted

 Mild > 70
 Moderate 50-70
 Severe < 50
 When you see the tracings below, which of
these prompts should you give the
participant
 Take in a deeper breath  Try not to cough
 Blow out harder  Blow out longer
and faster  Good Test
 The flow volume loop below is
representative of
 Extrapolation or time  Obstructive pattern

zero error  Restrictive pattern

 Clipped inspiratory loop  Glottic closure
 When you see the tracings below, which of these
prompts should you give the participant

 Blow out longer

 Good Test

 Take in a deeper breath

 Try not to cough

 Blow out harder and faster

When you see the tracings below, which of these
prompts should you give the participant
 Take in a deeper breath  Try not to cough
 Blow out harder  Blow out longer
and faster  Good Test
 The flow volume loop below is
representative of
 Extrapolation  Obstructive pattern
or time zero error
 Clipped inspiratory loop  Restrictive pattern

 Glottic closure
Back Extrapolation
Exhalation Time During Obstruction
Spirometry-Induced Bronchospasm
Coaching is Key
Bronchodilator Response
Obstruction
Restrictive Pattern
 Patient example

Child with inspiratory stridor

-

-
Vocal Cord Dysfunction
 Patient example

 12 year old boy presents with exercise-

induced wheeze for 1 year
 Not responsive to bronchodilator used pre-
exercise, ICS, OCS
 Fixed airway obstruction

 Obstruction due to abnormalities of the vocal

cords after trauma of intubation and
prolonged intubation
 Additional history

 Automobile accident at age 11 years

 Intubated at scene of accident
 Comatose for 1 month, followed by complete
neurologic recovery
 FEF 25-75%

 What is it?
 What does it measure?
 Is it a measure of small airways?
 FEF 25-75%
 What is it?
• Mean expiratory flow during middle half of FVC maneuver
 What does it measure?
• Flow from airways that empty in the middle half of FVC
maneuver
 Is it a measure of small airways?
• Maybe in normals
• In asthma, or obstructive disease, it measures flow from
more obstructed airways which could be small or larger
with more obstruction
A problem with FEF: Variability
 Dysanapsis
 Green, Mead, Turner. Variability of maximum expiratory
flow-volume curves. J Appl Physiol 1974 37:67-74
• Variability in flows among healthy adults not altered when
flows were corrected for vital capacity
• Lung static recoil and bronchomotor tone contributed little
to variability
Concluded that variability in flows between individuals
due to differences in airway size independent of
lung/parenchyma size
Differences may have embryological basis, reflecting
disproportionate but physiologically normal growth within
an organ
 Dysanapsis
 Mead. Dysanapsis in normal lungs assessed by the
relationship between maximal flow, static recoil, and vital
capacity. Am Rev Respir Dis 1980 121:339-342
• “There is no association whatsoever between
airway diameter and lung size.”
• There are differences between men and women
(men 17% larger than women) and between boys
and men (boys in late teens similar to girls,
suggesting that growth in males occurs late)
 Measures Of Dysanapsis
 Mead used maximal expiratory flow/static recoil
pressure at 50% VC
 Weiss and coworkers have used
FEF25-75/FVC as a surrogate
 FEF25-75/FVC is correlated with
FEV-1/FVC
 FEV-1/FVC is the best measure: obtained from
spirometry and normal values available
 Dysanapsis Is Affected By Asthma
 Weiss et al. Effects of asthma on pulmonary function in
children. A longitudinal population-based study. Am Rev
Respir Dis 1992 145:58-64.
• East Boston cohort of 5-9 year old school children followed
prospectively until age 13 years
• Active asthma
• Yes to “Has a doctor ever told you that your child has asthma.”
• Wheezing symptoms present in that study year
• Boys with asthma had significantly larger FVC, but normal
FEV-1
• Girls with asthma had significantly lower FEV-1, but normal
FVC
Compared to children with no history of asthma, after adjusting for
previous level of pulmonary function, age, height, and personal and
maternal smoking
 Clinical Correlates Of Asthma
Related To Dysanapsis
 Studies of East Boston cohort of school children
by Weiss and colleagues
 Degree of response to eucapneic hyperventilation:
• Correlated with FEF25-75/FVC, but not FEF25-75
• Correlated with FVC (higher levels associated with
increased response)
In both studies, response also correlated with current
asthma and report of a respiratory illness that led to
activity restriction
 Case History of dysanapsis

 Pulmonary function results at age 7

• FVC 157% predicted
• FEV-1 115% predicted
 Case History

 Pulmonary function results at age 7

• FVC 157% predicted (82-120%)
• FEV-1 115% predicted (82-120%)
 Case History

 Pulmonary function results at age 7

• FVC 157% predicted (82-120%)
• FEV-1 115% predicted (82-120%)

• FEV-1/FVC = 65% (> 80%)

 Case History
 Pulmonary function results at age 7
• FVC 157% predicted
• FEV-1 115% predicted
• FEV-1/FVC = 65%
 Results obtained 1 month after severe
exacerbation requiring intubation and
ventilation
 1st admission occurred at age 21 months
 Intubation admission was #28, with first
documented hypercarbia with exac at age
4 years
 Spirometry History
Age FVC % pred FEV-1 % pred FEV-1/FVC
6 143 126 79
7 157 115 65
8 149 119 72
9 159 129 73
10 127 95 66
11 147 96 58
12 119 91 67
13 100 77 71
14 78 57 68
 Conclusions
 Spirometry is:
• Useful in asthma diagnosis and management
• Useful in diagnosis of conditions that can present with
wheezing, or airway noise that can be hard to
distinguish from wheezing
• Requires considerable expertise, particularly in children
 FEF25-75% does not measure small airways, but
instead airways more obstructed that empty later
in exhalation