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Dr. R.V.S.N.Sarma.,Dr. R.V.S.N.Sarma., M.D., M.Sc., M.D., M.Sc.,

Consultant Physician & Chest SpecialistConsultant Physician & Chest Specialist

E mail: E mail: [email protected]@gmail.com

3760 9226 or 2766 05933760 9226 or 2766 0593

93805 21221 or 98940 6059393805 21221 or 98940 60593

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Pulmonary Function TestsPulmonary Function Tests

Ventilatory Function – Ventilatory Function – Spirometry Spirometry

ClinicalClinical ApplicationsApplications

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LUNG FUNCTION TESTSLUNG FUNCTION TESTS

Tests of VentilationTests of VentilationTests of DiffusionTests of DiffusionTests of PerfusionTests of PerfusionTests for V-P Tests for V-P

MismatchMismatch

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Function of VentilationFunction of Ventilation

Air ExitAir Exit – Airways, Bronchomotor tone, – Airways, Bronchomotor tone, Secretions, Thoracic muscles etcSecretions, Thoracic muscles etc

Air EntryAir Entry – Expansion of lungs – – Expansion of lungs – Functioning lung volume, its elastic Functioning lung volume, its elastic nature, Lung compliancenature, Lung compliance

‘‘Air Out’ ProblemAir Out’ Problem – Obstructive – Obstructive DiseasesDiseases

‘‘Air In’ problemAir In’ problem – Restrictive Diseases – Restrictive DiseasesBothBoth Air Out and In - Combined Air Out and In - Combined

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Objectives Objectives To detect Obstructive Airway Diseases To detect Obstructive Airway Diseases To quantify the severity of obstruction. To quantify the severity of obstruction. To assess response to IBD. To assess response to IBD. To identify Restrictive Lung Diseases.To identify Restrictive Lung Diseases. To identify flow-volume loop patternsTo identify flow-volume loop patterns To understand the clinical relevance. To understand the clinical relevance.

Spirometry Spirometry

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PEAK FLOW METERPEAK FLOW METER

Diagnosis of ASTHMA or COPD can beDiagnosis of ASTHMA or COPD can beconfirmed by demonstrating the confirmed by demonstrating the

presencepresenceof airway obstruction using of airway obstruction using Spirometry.Spirometry.

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PEFR - Pros and ConsPEFR - Pros and Cons

AdvantagesAdvantagesWith in 1 to 2 minutes,With in 1 to 2 minutes,Inexpensive (meter costs less than Rs.1000)Inexpensive (meter costs less than Rs.1000)Simple, useful for frequent follow up useSimple, useful for frequent follow up use

DisadvantagesDisadvantagesVery much effort dependentVery much effort dependentInsensitive to small changesInsensitive to small changesSmall airways cannot be assessedSmall airways cannot be assessedLarge inter & intra subject Large inter & intra subject

variation;variation;↓accurate↓accurate

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SPIROMETRYSPIROMETRY

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Spirometry - Pros and ConsSpirometry - Pros and ConsAdvantagesAdvantages

Evaluates smaller as well as larger airwaysEvaluates smaller as well as larger airwaysRelatively easy to use and maintainRelatively easy to use and maintainReversibility can be tested with IBD and steroidsReversibility can be tested with IBD and steroidsDiagnostic as well as management assessmentsDiagnostic as well as management assessments

DisadvantagesDisadvantagesCosts about 50,000 + computer and printerCosts about 50,000 + computer and printerTakes time to perform – 10 to 15 minutesTakes time to perform – 10 to 15 minutesRequires training – at least one day courseRequires training – at least one day course

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Spirometry ManeuverSpirometry Maneuver

In single breath testIn single breath testA few normal tidal respirationsA few normal tidal respirationsThen deeeeep inspirationThen deeeeep inspirationMomentary breath holdingMomentary breath holdingVery forced and fast expirationVery forced and fast expiration

As hard and as fast as he/she can blow As hard and as fast as he/she can blow outout

Then deep, quick and full inspirationThen deep, quick and full inspirationRepeat Repeat at least 3at least 3 times – take times – take the bestthe best

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Reproducibility of SpirometryReproducibility of Spirometry

Adequate explanation to the patientAdequate explanation to the patientDemonstrating the steps one by oneDemonstrating the steps one by oneEncouraging the patient to give best effortEncouraging the patient to give best effortTaking at least 3 and usually 5 attemptsTaking at least 3 and usually 5 attemptsSelecting the best effortSelecting the best effortCough and severe dyspnoea may interfereCough and severe dyspnoea may interfereNot like ECG – Not like ECG – Results depend on effortResults depend on effort

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Spirometry ResultsSpirometry ResultsFVC FVC Forced Vital CapacityForced Vital CapacityFEVFEV11 Forced Expiratory Forced Expiratory

Volume Volume in the first second in the first second FEVFEV11/FVC /FVC Ratio of the above twoRatio of the above two

PEFRPEFR Peak Expiratory Flow Peak Expiratory Flow RateRate

FETFET Forced Expiratory TimeForced Expiratory Time

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Normal

Flow-Volume

Volume-Time

Test Values

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Spirometry ResultsSpirometry ResultsFVC FVC Forced Vital CapacityForced Vital CapacityFEVFEV11 Forced Expiratory Forced Expiratory

Volume Volume in the first second in the first second FEVFEV11/FVC /FVC Ratio of the above twoRatio of the above two

PEFRPEFR Peak Expiratory Flow Peak Expiratory Flow RateRate

FETFET Forced Expiratory TimeForced Expiratory Time

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Spirometry Normal ValuesSpirometry Normal Values1.1. There are no fixed ‘Normal’ valuesThere are no fixed ‘Normal’ values

2.2. Dependent on age, sex, height, weight, ethnicityDependent on age, sex, height, weight, ethnicity

3.3. Observed value expressed as % of predicted Observed value expressed as % of predicted valuevalue

FVC FVC Normal if > 80% of predictedNormal if > 80% of predicted FEV1FEV1 Normal if > 80% of predictedNormal if > 80% of predicted FEV1/FVC FEV1/FVC At least 75%At least 75% PEFRPEFR Normal if > 80% of predictedNormal if > 80% of predicted FETFET Less than 4 secondsLess than 4 seconds

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The Four Square GameThe Four Square GameF

EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.

FVC NORMALFVC < 80% Pred.

80%

80%

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The Four Square GameThe Four Square Game


80%

80%

Normal LungsFEV1÷FCV is N

FE

V1

NO

RM

AL

FE

V1 <

80%

of

Pd

.

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80%

80%

FE

V1

NO

RM

AL

FE

V1 <

80%

of

Pd

.

Obstructive Disease

FEV1÷FCV is Low

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80%

80%

FE

V1

NO

RM

AL

FE

V1 <

80%

of

Pd

.

Restrictive Disease

FEV1÷FCV is High

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EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


80%

80%

Combined Obs+Res

FEV1÷FCV is N or L

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EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


80%

80%


Obstructive Disease

FEV1÷FCV is Low

Restrictive Disease

FEV1÷FCV is High

Combined Obs+Res

FEV1÷FCV is N or L

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EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


80%

80%

Normal AirEntry & Exit

Air Exit ProblemAirways choked

Air Entry ProblemLungs ↓

expansion

Both Air Entry &Air Exit Problem

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EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


80%

80%


Obstructive Disease

FEV1÷FCV is Low

Restrictive Disease

FEV1÷FCV is High

Combined Obs+Res

FEV1÷FCV is N or L

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Millers Prediction QuadrantsMillers Prediction QuadrantsF

EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


Air In and Out NNormal LungsFEV1÷FCV is N

Air Exit is chockedObstructive

Disease

FEV1÷FCV is Low

Air Entry is reduced

Restrictive Disease

FEV1÷FCV is High

Both Air In & Out ↓↓

Combined Obs+Res

FEV1÷FCV is N or L

90% 100%70% 80%60%

90%

100%

70%

60%

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Algorithm for DiagnosisAlgorithm for Diagnosis

FVC

FVC > 80% FVC < 80%

FEV1 > 80% FEV1 < 80%

Normal PFT Obstructive

Reversible Irreversible Extra-pulmonary

FEV1 < 80%FEV1 > 80%

Restrictive Combined

Pulmonary

IBD

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Normal Airways and LungsNormal Airways and Lungs

FVC FVC > 80%> 80% FEVFEV11 > 80%> 80% FEVFEV11÷FCV÷FCV> 75%> 75%

PEFRPEFR > 80%> 80% FETFET <4 sec<4 sec

Air Entry NormalAir Entry Normal Air Exit Air Exit Normal Normal

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

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Normal Airways - PFTNormal Airways - PFT

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Normal PFT and CXRNormal PFT and CXR

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Bronchial Asthma – Reversible Airway Bronchial Asthma – Reversible Airway obs.obs.

Chronic bronchitis – Irreversible with IBDChronic bronchitis – Irreversible with IBDEmphysema – Irreversible with IBDEmphysema – Irreversible with IBDBronchiectasis – Airway rigidityBronchiectasis – Airway rigidityCystic FibrosisCystic FibrosisAllergic bronchopulmonary AspergillosisAllergic bronchopulmonary AspergillosisBronchiolitis Bronchiolitis

Obstructive Airways DiseaseObstructive Airways Disease

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Obstructive Airways DiseaseObstructive Airways Disease

FVC FVC > 80%> 80% FEVFEV11 < 80%< 80% FEVFEV11÷FCV÷FCV< 75%< 75%

PEFRPEFR < 80%< 80% FETFET >4 sec>4 sec

Air Entry NormalAir Entry Normal Air Exit Air Exit Problem Problem

FEV1 is LOW

FVC is Normal


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Obstructive Airways Disease - Obstructive Airways Disease - PFTPFT

FEV1 is LOW

FVC is Normal


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Obstructive V/s NormalObstructive V/s Normal

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Obstructive Airways MildObstructive Airways Mild

Bronchial Asthma

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Bronchial Asthma

Reversible Obstruction (IBD)Reversible Obstruction (IBD)

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Bronchiectasis (Obstructive)Bronchiectasis (Obstructive)

BRONCHOGRAM - BIL UNILATERAL

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Obstructive Airways SevereObstructive Airways Severe

Emphysema

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Obstructive Airways Severe -Obstructive Airways Severe -IBDIBD

Emphysema

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Obstructive Lung DiseasesObstructive Lung Diseases

ABPA CYSTIC FIBROSIS

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Upper Airway ObstructionUpper Airway Obstruction

Truncation of flow loop Truncation of flow loop Expiratory – Intra ThoracicExpiratory – Intra Thoracic Inspiratory –Extra Inspiratory –Extra

ThoracicThoracic Both – Fixed ObstructionBoth – Fixed Obstruction

TumourTumour Tracheal stenosisTracheal stenosis Tracheal FBTracheal FB Vocal Chord DysfunctionVocal Chord Dysfunction

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Restrictive Lung DiseasesRestrictive Lung Diseases

SarcoidosisSarcoidosisTuberculosis – (Fibrocaseous)Tuberculosis – (Fibrocaseous) Interstitial Lung Disease - ILD Interstitial Lung Disease - ILD Idiopathic pulmonary fibrosis - IPFIdiopathic pulmonary fibrosis - IPFPneumoconiosisPneumoconiosisDrug- or radiation-induced lung Drug- or radiation-induced lung

diseasediseasePneumonectomyPneumonectomy

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Extrinsic Restrictive DiseasesExtrinsic Restrictive Diseases

Kyphosis, ScoliosisKyphosis, ScoliosisAnkylosing SpondylitisAnkylosing SpondylitisMassive Pleural effusionMassive Pleural effusionPregnancy, Obesity, AscitesPregnancy, Obesity, AscitesRib fracturesRib fracturesNeuromuscular disordersNeuromuscular disorders

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Restrictive Lung DiseaseRestrictive Lung Disease

FVC FVC < 80%< 80% FEVFEV11 > 80%> 80% FEVFEV11÷FCV÷FCV> 75%> 75%

PEFRPEFR > 80%> 80% FETFET <4 sec<4 sec

Air Entry ProblemAir Entry Problem Air Exit Air Exit Normal Normal

FEV1 is LOW

FVC is Normal


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Restrictive Lung Disease - PFTRestrictive Lung Disease - PFT

FEV1 is LOW

FVC is Normal


ILD or IPF

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Restrictive V/s NormalRestrictive V/s Normal

ILD or IPF

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ILD or IPF

Restrictive Lung Disease - ILDRestrictive Lung Disease - ILD

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HEPATIOD APPEARANCE

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RETICULAR PERIPHERIES

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HRCT Chest X-RAY CHEST - ILD

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Restrictive Lung DiseasesRestrictive Lung Diseases

SARCOIDOSIS RETICULO-NODULAR

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Combined Obstructive + Combined Obstructive + RestrictiveRestrictive

FVC FVC < 80%< 80% FEVFEV11 < 80%< 80% FEVFEV11÷FCV÷FCV< 75%< 75%

PEFRPEFR < 80%< 80% FETFET >4 sec>4 sec

Air Entry ProblemAir Entry Problem Air Exit Air Exit Problem Problem

FEV1 is LOW

FVC is Normal


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FEV1 is LOW

FVC is Normal


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KOCHS + EMPHYSEMA

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Other PatternsOther Patterns

FIXED OBSTRUCTION

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Other PatternsOther Patterns

EXTRA THORACIC

COUGH

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Case 1Case 1

TestTest Pred.Pred. MeasMeas..

%%

FVCFVC 5.5 L5.5 L 4.5 L4.5 L 82%82%

FEV1FEV1 4.9 L4.9 L 3.0 L3.0 L 61%61%

RatioRatio 89%89% 66%66% --

Man, aged 28, 172cm, 71kg

Non smoker, Cough 3 M

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Case 1Case 1


Non smoker, Cough 3 M

Dx : Bron Asthma - Rev

IBD Good Response


%%

FVCFVC 5.5 L5.5 L 4.5 L4.5 L 82%82%

FEV1FEV1 4.9 L4.9 L 3.0 L3.0 L 61%61%

RatioRatio 89%89% 66%66% --

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Case 2Case 2

Woman, 48 y, 155cm, 47 kg

Non smoker, Dysp., CP


%%

FVCFVC 3.9 L3.9 L 2.6 L2.6 L 66%66%

FEV1FEV1 3.1 L3.1 L 2.4 L2.4 L 78%78%

RatioRatio 79%79% 92%92% --

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Case 2Case 2


Non smoker, Dysp., CP

Diagnosis : # Ribs 5,6,7,8


%%

FVCFVC 3.9 L3.9 L 2.6 L2.6 L 66%66%

FEV1FEV1 3.1 L3.1 L 2.4 L2.4 L 78%78%

RatioRatio 79%79% 92%92% --

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Case 3Case 3


%%

FVCFVC 6.0 L6.0 L 5.0 L5.0 L 83%83%

FEV1FEV1 4.8 L4.8 L 4.1 L4.1 L 85%85%

RatioRatio 80%80% 82%82% --

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

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Case 3Case 3


%%

FVCFVC 6.0 L6.0 L 5.0 L5.0 L 83%83%

FEV1FEV1 4.8 L4.8 L 4.1 L4.1 L 85%85%

RatioRatio 80%80% 82%82% --

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

Diagnosis : Normal PFT

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Case 4Case 4

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.


%%

FVCFVC 1.9 L1.9 L 0.7 L0.7 L 36%36%

FEV1FEV1 1.6 L1.6 L 0.4 L0.4 L 25%25%

RatioRatio 84%84% 57%57% --

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Case 4Case 4

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.


%%

FVCFVC 1.9 L1.9 L 0.7 L0.7 L 36%36%

FEV1FEV1 1.6 L1.6 L 0.4 L0.4 L 25%25%

RatioRatio 84%84% 57%57% --

FB in the UAW

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Case 5Case 5


Had ATT, Dysp G3, Wheeze


%%

FVCFVC 3.5 L3.5 L 1.8 L1.8 L 51%51%

FEV1FEV1 2.8 L2.8 L 1.2 L1.2 L 43%43%

RatioRatio 80%80% 66%66% --

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Case 5Case 5

Diagnosis : TB + ABPA


%%

FVCFVC 3.5 L3.5 L 1.8 L1.8 L 51%51%

FEV1FEV1 2.8 L2.8 L 1.2 L1.2 L 43%43%

RatioRatio 80%80% 66%66% --


Had ATT, Dysp G3, Wheeze

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Case 6Case 6


Smoker 16yr, Severe Dysp.


%%

FVCFVC 4.5 L4.5 L 3.7 L3.7 L 82%82%

FEV1FEV1 3.6 L3.6 L 1.8 L1.8 L 50%50%

RatioRatio 80%80% 49%49% --

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Case 6Case 6


Smoker 16yr, Severe Dysp.

DX :COPD- Irreversible


%%

FVCFVC 4.5 L4.5 L 3.7 L3.7 L 82%82%

FEV1FEV1 3.6 L3.6 L 1.8 L1.8 L 50%50%

RatioRatio 80%80% 49%49% --

IBD NO Response

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EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


80%

80%


Obstructive Disease

FEV1÷FCV is Low

Restrictive Disease

FEV1÷FCV is High

Combined Obs+Res

FEV1÷FCV is N or L

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Millers Prediction QuadrantsMillers Prediction QuadrantsF

EV

1 N

OR

MA

LF

EV

1 <

80%

of

Pd

.


Air In and Out NNormal LungsFEV1÷FCV is N

Air Exit is chockedObstructive

Disease

FEV1÷FCV is Low

Air Entry is reduced

Restrictive Disease

FEV1÷FCV is High

Both Air In & Out ↓↓

Combined Obs+Res

FEV1÷FCV is N or L

90% 100%70% 80%60%

90%

100%

70%

60%

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Take Home PointsTake Home Points

All that wheezes All that wheezes is notis not Asthma only Asthma onlyAll Dyspnoea All Dyspnoea does notdoes not wheeze wheeze Do not over simplify dyspnoea to DeriphyllinDo not over simplify dyspnoea to DeriphyllinEtiology of Dyspnoea needs elucidationEtiology of Dyspnoea needs elucidationSpirometry tests but Ventilation function Spirometry tests but Ventilation function

onlyonlyNeed to test diffusion, Perfusion functions Need to test diffusion, Perfusion functions Cardiac, Hematologic and other causes

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