PULMONARY FUNCTION

TESTS

MODERATOR - DR. NEELKAMAL MISHRA

PRESENTER - DR. GOWTHAM KUMAR N
 SYNOPSIS

INTRODUCTION AND CLASSIFICATION

LUNG VOLUME AND CAPACITIES
METHODS FOR MEASUREMENT
FLOW - VOLUME LOOPS
ANAESTHETIC CONSIDERATIONS
BED SIDE TESTS
INTERPRETATION OF PFT
 INTRODUCTION AND
CLASSIFICATION
MECHANICAL AND
VENTILATORY GAS EXCHANGE TESTS
FUNCTION OF LUNG 1. ALVEOLO ARTERIAL po2
AND CHEST WALL GRADIENT
2. DLCO
1. STATIC LUNG FUNCTION 3. VENTILATION PERFUSION
TESTS TEST BY ABG
2. DYNAMIC LUNG FUNCTION
TESTS

CARDIOPULMONARY
INTERACTION
1. QUALITATIVE TESTS LIKE HISTORY,
ABG AND STAIR CLIMBING TESTS
2. QUANTITATIVE TEST LIKE 6 MINUTE
WALK TEST (GOLD STANDARD)
LUNG VOLUMES AND
CAPACITIES
STATIC LUNG FUNCTION TEST

1. STATIC LUNG 1. STATIC LUNG

VOLUMES CAPACITIES
A. Tidal volume A. Inspiratory
B. Inspiratory reserve capacity
volume B. Functional residual
C. Expiratory reserve capacity
volume C. Vital capacity
D. Residual volume D. Total lung capacity
E. Closing volume E. Closing capacity
LUNG VOLUMES AND
CAPACITIES
TIDAL VOLUME: Volume of air inspired and
expired while normal quiet breathing 6-8ml/kg

INSPIRATORY RESERVE VOLUME:

Maximum amount of air that can be inhaled after
normal tidal volume 2000-3200ml (3000ml)

EXPIRATORY RESERVE VOLUME :

Maximum amount of air that can be expired from
resting expiratory level 1000-1500ml (1200ml)
 LUNG VOLUMES AND
CAPACITIES
RESIDUAL VOLUME : Volume of air remaining
in the lungs after maximum expiration 1500-
2000ml

CLOSING VOLUME: Volume of air at which the

lower most alveolar airways begin to close

INSPIRATORY CAPACITY: Maximum volume

of air that can be inhaled from end of tidal volume
expiration IC = IRV+TV 3000-3500ml
LUNG VOLUMES AND
CAPACITIES
VITAL CAPACITY: Volume of air that can be
exhaled after a maximum inspiration
VC = IRV+TV+ERV 4000-4500ml

FUNCTIONAL RESIDUAL CAPACITY:

Volume of air remaining in the lungs at the end of
tidal volume expiration FRC = ERV+RV 2500-
3000ml

 CLOSING CAPACITY: Volume of air inside

lungs after the lowermost alveoli are closed along
with residual volume CC=CV+RV
 LUNG VOLUMES AND
CAPACITIES
TOTAL LUNG CAPACITY: Total volume of
air inside lungs after maximum inspiration
TLC= IRV+TV+ERV+RV. Very good indicator
of restrictive lung disease. Normal value is 6-6.5
Lit

70-80% of predicted is mild restriction

60-70% of predicted is moderate
restriction
<60% of predicted is severe restriction
LUNG VOLUMES AND
CAPACITIES
DYNAMIC LUNG FUNCTION TEST

1. FORCED VITAL
CAPACITY(FVC)
2. FORCED EXPIRATORY
VOLUME (FEV)
3. TIFFENEAU – PINELLI INDEX
4. PEAK EXPIRATORY FLOW(PEF)
5. MAXIMUM MID EXPIRATORY
FLOW (MMEF) or (FEF 25-75%)
6. MAXIMUM VOLUNTARY
VENTILATION( MVV )
 LUNG VOLUMES AND
CAPACITIES
FORCED VITAL CAPACITY: volume of air
that can be exhaled forcefully and rapidly after a
deep inspiration

80-120% of predicted value is Normal

70-79% is mild decrease
60-69% is moderate decrease
50-59% is moderate - severe decrease
35-49% severe decrease
<35% is very severe decrease
LUNG VOLUMES AND
CAPACITIES
 FORCED EXPIRATORY VOLUME : Amount of air in FVC
exhaled over given time
50-60% of FVC at 0.5
second
75-85% of FVC at 1 second
94% of FVC at 2 seconds
97% of FVC at 3 seconds

 MAXIMUM VOLUNTARY VENTILATION: Maximum amount

of air a person breathes in one minute. It indicates muscle
bellows, airway resistance and lung compliance. Normal is
160-180Lit/Min.
LUNG VOLUMES AND
CAPACITIES
TIFFENEAU – PINELLI INDEX : Ratio of FEV1
and FVC normally it should be above 0.7

PEAK EXPIRATORY FLOW RATE: it is the

maximum flow rate achieved during FVC
maneuver. Normal is 3-5 lit/sec

MAXIMUM MID EXPIRATORY FLOW: it is the

amount of air exhaled during middle half of the
FVC maneuver i.e 25% of FVC to 75% of FVC it is
4700ml/sec or 280lit per min. It reflects the small
sized airways obstruction and it is an early indicator.
DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
Gas diffuses between alveoli and blood
The membrane thickness for diffusion is 0.2-
0.5microns and surface area is 70mts sq.
Diffusion of gas obeys ficks law
 DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
Usually blood stays in the pulmonary capillary for
0.75 sec.
CO diffuses into the blood throughout this 0.75 sec
and no equilibrium achieved and this will be
affected if the membrane is damaged hence called
diffusion limited gas. Normal range of DLCO is
17-25ml/min/mm of Hg
Nitrous oxide will attain equilibrium at 0.1 sec
itself and further diffusion occurs if new blood
comes hence called perfusion limited gas
DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
Oxygen will attain equilibrium at 0.3 sec and
this is also perfusion limited gas. Oxygen will
become diffusion limited in pulmonary fibrosis
and emphysema
DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
Oxygen has 1.23 times more the diffusion
coefficient of CO
So diffusion capacity of oxygen is 25*1.23
gives 30ml/mt/mm of Hg
DLCO
1. 80% of predicted is normal
2. 60-80% is mild reduction
3. 40-60% is moderate reduction
4. Less than 40% is severe reduction
DIFFUSION CAPACITY TO DETERMINE
ALVEOLO-CAPILLARY MEMBRANE:
After coming to a diagnosis of decreased DLCO
we can furthur narrow down our diagnosis with
help of TLC
Decreased DLCO

Increased TLC Decreased TLC Normal TLC

Emphysema Pulmonary fibrosis PVD
.

DLCO will increase in left to right shunt and

intrapulmonary bleeding
CARDIOPULMONARY EXERCISE
TEST

STAIR SIX MINUTE

CLIMBING WALK TEST
TEST
If patient able to
If patient is able to
climb 3 flights of
walk more than 2000
stairs without
feet for 6 minutes
stopping or having
without fall in
dyspnoea in his or her
spo2>4% his/her Vo2
own pace indicates
max is greater than
reduced morbidity
15ml/kg/mt
and mortality
METHODS FOR MEASUREMENT

WHOLE BODY
PLETHYSMOGRAPHY
SPIROMETRY
HELIUM DILUTION METHOD
NITROGEN WASHOUT METHOD
FVC MANEUVER
 SPIROMETRY
Spirometry derived from the latin word (Spiro -
to breathe and Meter –to measure)
Spirometry is the method of assesing the lung
function by measuring the volume of air that the
patient can expel from lungs after deep
inspiration
Nose clip is applied to prevent air escaping
Useful in assesing airflow obstruction
 FLOW - VOLUME LOOPS
Flow rate in Lit/Sec is plotted in Y-Axis
Volume in Lit. is plotted in X-Axis
Leftmost end of the curve represents TLC
Rightmost end of the curve represents RV
Width of the curve represents FVC
Height of curve represents PEF
Distance from TLC to 1sec mark represents
FEV1
The curve has 2 parts effort dependent part and
effort independent part
 FLOW - VOLUME LOOPS

EFFORT
EFFORT
DEPENDENT PART
•Part of the curve from INDEPENDENT
TLC to PEF PART
•This part depends on •Part of the curve from
expiratory effort, PEF to Residual Volume
velocity and force of •This part is independent
expiratory muscle and reflects peripheral
contraction airway resistance and
lung elastic recoil
 FLOW - VOLUME LOOPS
UPPER AIRWAY OBSTRUCTION

VARIABLE FIXED

Extrathoracic Intrathoracic occurs in both

Occurs in Occurs in inspiration and
inspiration expiration expiration
Tracheomalacia
Vocal cord palsy Foreign body
Polychondritis
Neuromuscular Goitre
Tracheal and
disorder Bronchial
main bronchial
OSA stenosis
tumors
 FLOW - VOLUME LOOPS
Extrathoracic obstruction occurs in inspiration
because the upper airways have subatmospheric
pressure while inspiration so it gets collapsed
and obstructed.
Intrathoracic obstruction occurs in expiration
because while expiration intrathoracic pressure
rises compressing the intrathoracic airways.
 FLOW - VOLUME LOOPS
OBSTRUCTIVE PATTERN
Pt cant exhale forcefully
Because of lost elastic recoil
So FEV1 reduced more
FVC also decreases
TI is less than 0.7
FEF 25-75% decreases
PEFR is reduced
Not reversed by bronchodilators
 FLOW - VOLUME LOOPS
OBSTRUCTIVE PATTERN
Highly compliant lung
Air trapping occurs
If so RV increases
FRC and TLC increases
Deep and slow breaths
Dogleg pattern is due to
smaller airway obstruction
 FLOW - VOLUME LOOPS
RESTRICTIVE PATTERN:
Miniature version
FVC is decreased
FEV1 is also decreased
TI is normal and
FEF 25-75% is normal
PEF is preserved or increased
Elastic recoiling will be more
Poor compliant lung
Fast shallow breaths
ANAESTHETIC CONSIDERATION
FRC is kept inside lung
As age increases,
Respiratory muscle mass by negative intrapleural
decreases pressure which is due to
Tissue elasticity decreases
Elastic recoil decreases chest wall tends to
More air retained in lung
Residual volume increases move outward and lung
Thereby FRC and CC increase
elastically recoils

After giving muscle relaxant, the outward force is

abolished and FRC tend to decrease but CC is
unaffected and when FRC falls below CC there
Occurs impaired oxygenation due to shunting.
ANAESTHETIC CONSIDERATION
 Therefore, PEEP in mechanical ventilation and
CPAP in spontaneous ventilation and adequete
NMB reversal is recommended in old age people
 COPD patients are tend to develop auto PEEP
due to air trapping which in turn due to loss of
elastic recoiling leading to Equal Pressure Point
development causing flow limitation.
 Thus, COPD patient on furthur PPV will develop
increased intrathoracic pressure and decreased
venous return leading to hypotension and cardiac
arrest may result in “ LAZARUS SYNDROME”
 ANAESTHETIC CONSIDERATION

PREOXYGENATION
WITHOUT Break point is 2 – 3
PREOXYGENATIO minutes
PREOXYGENATED
PCo2 can go till 60
N: AND
mmHg
Break point is 1 min HYPERVENTILATE
HYPERVENTILATE D:
Po2 fall be 65-75 Apneic period will go
mmHg D
upto 6-10 minutes
PCo2 washed out by
PCo2 rise by 50 mm 20mmHg
Hg Breakpoint increased
by 3-4 minutes
 BED SIDE PFTs
 DE BONO’S WHISTLE TEST
 SNIDER’S MATCH BLOWING TEST
 SEBRASEZ’S BREATH HOLDING TIME
 SEBRASEZ’S SINGLE BREATH COUNT
 COUGH TEST
 WRIGHT’S SPIROMETER
 PEAK EXPIRATORY FLOW METER
 MICROSPIROMETERS
 VITALOGRAPH
 ABG AND PULSEOXYMETRY
 BED SIDE PFTs
 DE BONO’S WHISTLE TEST:
 Used to measure PEFR
 Has outer cardboard tube and inner plastic
tube with slot on the side and whistle at the
end
 Outer cardboard can be slided over inner
tube
 The slot works as leak hole and plastic tube
has scale on it in increments of 100lit/mt
 The leak hole size is gradually increased
and the patient is asked to blow through the
mouth piece and the last hole size at which
patient sounds the whistle gives PEFR
 BED SIDE PFTs
SNIDER’S MATCH BLOWING TEST:
 Patient sits comfortable and head held erect and
chin supported
 Match stick is lighted and after initial flare of
light offs the stick is held 6 inches away from
patient and asked to blow it off
 Patient should not purse his/her lips
 If patient is able to blow it off at
3 Inches
6 Inches, MBC <60L/Mt and >40L/Mt
MBC >60L/mt
FEV1 >1.6L/mt 9 Inches,
MBC >150L/mt
 BED SIDE PFTs
SEBRASEZ’S BREATH HOLDING TIME:
 Patient asked to take deep breath and asked to hold it
and used to asses patient’s cardiopulmonary reserve
 >25 sec is good CP reserve and <15 sec is poor

SEBRASEZ’S SINGLE BREATH COUNT:

 Used to asses patient vital capacity
 Patient is asked to take a deep breath and start coun ting
numbers
 If patient counts greater than 40 indicates normal vital
capacity
 BED SIDE PFTs

COUGH TEST:
 Patient is asked to take deep breath and cough forcefully
 Used to asses vital capacity and respiratory muscle strength

Ineffective cough indicates,

FVC < 20ml/kg PEFR < 200ml/mt
FEV1 < 15ml/kg
 BED SIDE PFTs
WRIGHT’S SPIROMETER:

 Mechanical movement of vane caused

by kinetic energy of gas flow during
inspiration and expiration and it is
reflected by the movement of needle
against dial that is calibrated in litres
 BED SIDE PFTs
PEAK EXPIRATORY FLOW METER:
 Patient takes vital capacity breath and
asked to blow through the PEF meter
with mouth piece
 Three attempts are taken and averaged

Male : 450-700 L/Mt

Female : 350-500L/Mt
<200 L/Mt indicates poor cough and
increased postop complication