PRACTICAL APPLICATIONS OF PULMONARY

FUNCTION TESTS

MODERATOR : DR.G.P SINGH

PRESENTERS : DR.SWATI AGGARWAL
DR.KARTHIK PONNAPPAN
DR.JOKHOORAM
GOALS OF PREOPERATIVE PULMONARY
EVALUATION
1. To predict likelihood of pulmonary complications
2. Obtain quantitative baseline information which can
help in decision making
3. Identify patients who may benefit from ???
bronchodilator therapy
4. To ascertain predictive benefit in pneumonectomy
patients
 INDICATIONS OF PRE-OP SPIROMETRY
Patient
Known pulmonary dysfunction
Currently smoking, especially if >1 pack per day
Chronic productive cough
Recent respiratory infection
Advanced age
Obesity >30% over ideal weight
Thoracic cage deformity, such as kyphoscoliosis
Neuromuscular disease, such as amyotrophic lateral sclerosis or
myasthenia gravis
Procedure
Thoracic or upper abdominal operation
Pulmonary resection
Prolonged anesthesia
Contraindications for Spirometry

 Recent myocardial infarction

 Unstable angina

 Recent thoraco abdominal surgery

 Recent ophthalmic surgery

 Thoracic / Abdominal / Cerebral aneurysm

 Pneumothorax

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WHAT TESTS SHOULD BE DONE….???
Preoperative pulmonary evaluation must include:
1. History & physical examination
2. Chest x rays
3. ABG : chronic hypoxemics :- to guide ventilatory
management goals
4. Screening spirometry
5. Maximum voluntary ventilation
6. DLCO
7. Quantitative radionuclide scintigraphy
8. Maximum cardiopulmonary exercise studies
EFFECTS OF ANESTHESIA AND
SURGERY ON LUNG VOLUMES
TLC : decreases after abdominal surgery
VC: 25 to 50 % decrease within 1-2 days
postop , returns to normal in 1-2 weeks
RV : increses by 13 %
ERV :decreases by 25% after LAS
60% after UAS & thoracic Surg
TV :decreases by 20% within first 24 hours
returns to normal within 2 weeks
Pulmonary Compliance : Decreases by 33%
APPLIED ASPECTS OF SOME LUNG
CAPACITIES
VITAL CAPACITY
It reflects the patients ability to take
Deep breath
Cough
Clear excessive secretions
Vital capacity may be reduced by :
a. Alterations in muscle power
b. Pulmonary disease
c. Abdominal tumors (* pregnancy )
d. Abdominal pain
e. Abdominal splinting
f. Alterations in posture
POSITION LOSS OF VITAL CAPACITY ( in
percent )

Tredelenburg 14.5
Lithotomy 18
Left lateral 10
Right lateral 12
Bridge in dorsal 12.5

Prone position , unsupported 10

During anesthesia vital capacity reductions are of little significance , during

controlled ventilation lungs feel stiff .

It evaluates patient condition for weaning from ventilator should be >10-15 ml/kg of
body weight

Importance in post op period :

( if VC falls about 3* TV – artificial help may be needed to clear secretions )
RESIDUAL VOLUME
Depends on limits of chest wall expansion and small
airways collapse
Any increase in it signifies lung is larger than usual
and cannot empty adequately occurs in
- After thoracic operations
- OAD
FUNCTIONAL RESIDUAL CAPACITY
Normally FRC is 40-50% of the TLC
(30ml/kg IBW )

FRC determines two primary physiologic

functions
1. the elastic pressure–volume
relationships within the lung. At
FRC chest wall and the lung are in
equilibrium with each other
2. oxygen reserve when apnea occurs

It greatly influences ventilation–perfusion relationships within the lung

(when FRC is reduced , venous admixture increases & results in arterial
hypoxemia , mechanism can b understood by its relationship with closing
capacity ) 11
FACTORS AFFECTING FRC
INCREASE
1. Age
2. OAD
3. Position

DECREASE
4. Age
5. Position
6. RLD
7. Anesthetic agents
8. Post operative period : upper abdominal : 40-50 %
Lower abdominal n thoracic : 30 %
Other : 15 – 20 % 12
Maximum Voluntary Ventilation (MVV)
The subject is instructed to breathe as hard and fast as possible for 10 to 15
seconds. The result is extrapolated to 60 seconds and reported in liters
per minute.
A low MVV can occur in obstructive disease, in restrictive disease, in
neuromuscular disease, in heart disease, in a patient who does not try or
who does not understand, or in a frail patient.

 MVV measures the endurance of the ventilatory muscles and

indirectly reflects lung–thorax compliance and airway resistance

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Maximum Voluntary Ventilation (MVV)
 MVV is the best ventilatory endurance test that can be performed
in the laboratory. Values that vary by as much as 30% from
predicted values may be normal, so only large reductions in MVV
are significant
 Healthy, young adults average ~170 L/min. Values are lower in
women and decrease with age in both sexes
 Because this manoeuvre exaggerates air trapping and exerts the
ventilatory muscles, MVV is decreased greatly in patients with
moderate-to-severe obstructive disease
 MVV is usually normal in patients with restrictive disease
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PFT IN THORACIC SURGERIES
Three Goals :
1. Identify the patient at risk of increased postoperative morbidity
and mortality
2. Identify patients who will need short term or long term post-op
ventilatory support
3. To evaluate beneficial effect and reversibility of airway
obstruction with use of bronchodilators

The 3 aspects of respiratory function need to be assessed pre

operatively and these form a 3 legged stool :
Lung Mechanics
Lung parenchymal function
Cardiopulmonary Interaction
1. RESPIRATORY MECHANICS
Many tests correlate with post
thoracotomy outcome :- FEV1, FVC,
MVV, RV/TLC
Most important of these is
predicted post operative (PPO) FEV1
PPO FEV1 = preop FEV1 % * (1- no
of subsegments removed /42 )
> 40% ~ low risk
30 to 40 % ~ moderate risk
< 30% ~ high risk
2. LUNG PARENCHYMAL FUNCTION
The lungs ability to exchanger O2 and CO2 between
pulmonary vascular bed and alveoli is assessed by :
1.ABG : cut offs PaO2 < 60 mmHg, PaCO2 > 45 mmHg , the
patients who do not meet these warning criterias are at
increased risk
2.DLCO : correlates with total functioning cross sectional area
of alveolar capillary interface, corrected DLCO can be used to
calculate post transection DLCO
ppoDLCO <40 % - correlates with increased respiratory and
cardiac complications
<20 %- unaccepatably high periop mortality rate
3.CARDIOPULMONARY INTERACTION
 Laboratory exercise testing – gold standard
 Maximal O2 Consumption (VO2max) – most useful
predictor of post-thoracotomy outcome
 Stair climbing

1 flight means 20 steps with 6 inches/step

5 flights - VO2max > 20 mL/kg/min

2 flights - VO2max > 12 mL/kg/min

 6MWT – 6 Minute Walk Test
 Less than 2000 feet (610 m) correlates to

VO2max < 15 mL/kg/min

 Fall in SpO2 more than 4 % during exercise

 Estimated ppoVO2max < 10 mL/kg/min is an

absolute contraindication for pulmonary
resection
V/Q SCINTIGRAPHY
 Assessment of preoperative contribution of
lobe or lung resected
 For any patient whose preoperative FEV1 and/or
less than 80%
APPROACH TO PFT
Spirometry is an effort dependent test therefore it is important to
ensure that subject gives his best while performing this test
Way of doing this is to look at the acceptability and repeatability
criteria
ACCEPTABILITY
1. No inadequate inspiratory effort
2. No slow / hesitated start
3. No cough
4. No poor effort
5. No early termination ( i.e FET >/= 6 seconds )
6. No glottic closure / obstruction of mouth piece due to tongue
REPEATABILITY
Difference between two best FEV1 and FVC must show minimum
variability. It should be within 200 ml
HOW MANY BLOWS….????
Atleast 3 acceptable / repeatable readings
Upto maximum of 8 blows are needed
CUT OFF VALUES
FVC >80%
FEV1 >70%
FEV1/ FVC >80 %
FEF25 – 75 > 60 %
Any suboptimal test must be interpreted with caution
because it may suggest the presence of disease when
none exists
STEPS FOR PFT INTERPRETATION
Step 1 SPIROMETRY
INTERPRETATION
Look at the flow-volume curve,
the FVC, and the FEV1/FVC ratio:
A.Does the curve suggest
obstruction ,restriction
B.Is the FEV1/FVC ratio reduced <
70 % - Obstruction
C.If the FEV1/FVC ratio is normal
and the TLC is below the lower
limit of normal → restriction
D. Examine expiratory flow values
FEF 25-75% : indicator of early
airway obstruction
E.Bronchodilator response is
positive if either the FEV1 or FVC
increases ≥ 12% and ≥ 200 mL.
Step 2FLOW-VOLUME
CURVE
Gives clues about the
presence of obstruction or
restriction.
Gives clues about unusual
conditions, such as the
following:
central airway obstructive
process , Neuromuscular
weakness
Step 3 LUNG VOLUMES
Obstructive disorders
have a TLC that is high
(hyperinflation) or
normal
An increased residual
volume (RV) (air
trapping) and an
increased RV/TLC ratio
Restrictive disorders
have a reduced TLC
Step 4 DLCO
Normal : in normal lungs ,
major airways lesion
Decreased : parenchymal ,
restrictive disorders , copd
Increased : alveolar
hemorrhage , very obese ,
asthma
Pulmonary Function Testing
 Ventilation  Blood Gases and pH
Forced Expiration  Mechanics of Breathing
Lung Volumes • Lung Compliance
• Airway Resistance
 Diffusion
• Closing Volume
 Blood Flow  Control of Ventilation
 Ventilation-Perfusion  Exercise Testing
Relationships
Topographical Distribution of
Ventilation and Perfusion
Inequality of Ventilation
Inequality of Ventilation-
Perfusion
Ratios
Ventilation
Dynamic Compression of Airways
OBSTRUCTIVE v/s RESTRICTIVE
Obstructive Disorders Restrictive Disorders
 Characterized by a  Characterized by reduced
limitation of expiratory lung volumes/decreased lung
airflow so that airways compliance
cannot empty as rapidly Examples:
compared to normal (such  Interstitial Fibrosis
as through narrowed airways  Scoliosis
from bronchospasm,  Obesity
inflammation, etc.)  Lung Resection
Examples:  Neuromuscular diseases
 Asthma  Cystic Fibrosis
 Emphysema
FEV1/FVC
In restrictive diseases, the maximum flow rate is
reduced, as is the total volume exhaled.
The flow rate is often abnormally high during the
latter part of expiration because of the increased lung
recoil.
By contrast, in obstructive diseases, the flow rate is
very low in relation to lung volume, and a scooped-
out appearance is seen.
OBSTRUCTIVE DISORDER

Rat tail appearance

Dog tail appearance
 RESTRICTIVE DISORDER

Tall and narrow with steep end-expiratory phase.

In obstructive disease, the total lung capacity is typically
abnormally large, but expiration ends prematurely.
The early airway closure is due to
1. increased smooth muscle tone of the bronchi, as in asthma,
2. loss of radial traction from surrounding parenchyma, as in
emphysema.
 Other causes include edema of the bronchial walls, or
secretions within the airways.
In restrictive diseases, inspiration is limited by the reduced
compliance of the lung or chest wall, or weakness of the
inspiration muscles.
The FEV1.0 (or FEF25–75%) is reduced by an increase
in airway resistance or a reduction in elastic recoil
of the lung.
It is independent of expiratory effort due to the
dynamic compression of airways.
The increase in airway resistance and the reduction of
lung elastic recoil pressure can be important factors in
the reduction of the FEV1.0, as, for example, in
pulmonary emphysema.
 Classification of COPD Severity
by Spirometry
Stage I: Mild FEV1/FVC < 0.70
FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.70

50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70

30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70

FEV1 < 30% predicted or
FEV1 < 50% predicted plus
Bronchial challenge testing -
Often used for asthma diagnosis
How?
Off inhalers
Check spirometry
Inhale a bronchoprovocator (histamine, methacholine,
saline) at inc. concentrations
measure spirometry after each inhalation
N.B. exercise as a bronchoprovocator
Bronchial challenge - interpretation
Threshold for positive may vary centre to centre
Indicates ‘Bronchial hyperresponsiveness’
Negative test virtually excludes asthma
False positives post-infection
Variable Extra-thoracic Airway Obstruction
 It is characterized by reduction of inspired flows during forced inspiration
with preservation of expiratory flows
 The causes are unilateral and bilateral vocal cord paralysis, vocal cord
adhesions, vocal cord constriction, laryngeal edema and obstructive sleep
apnea

 Surrounding soft tissue unsupporting

Collapses during inspiration
Expands during expiration

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Variable Intra-thoracic Obstruction
 It is produced by localized tumors of the lower trachea or main stem
bronchus, tracheomalacia , & airway changes associated with polychondritis
 In these obstructions, there is reduction of airflow during forced expiration
with preservation of a normal inspiratory flow configuration.

Outer surface exposed to pleural pressure

Expands during inspiration
Collapses during expiration

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Fixed Upper Airway Obstruction
 It is characterized by plateaus of flow during both forced inspiration &
expiration
 The causes include goitres, endotracheal neoplasms, stenosis of both main
bronchi, post intubation stenosis & performance of the test through a
tracheostomy tube or other fixed orifice device
 In these, there is reduction in airflow both during inspiration & expiration

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49
LUNG VOLUMES
Lung volumes by spirometry, and
functional residual capacity (FRC) by helium dilution
and body plethysmography
Lung Volumes
Helium Dilution
Body Plethysmograph
Single Breath Nitrogen Washout
 )

Fowler’s method for VD (Anatomical)

Bohr equation VD Physiological
Fick’s Diffusion law
Examples of diffusion- and perfusion-limited gases are
carbon monoxide and nitrous oxide, respectively.
Oxygen transfer is normally perfusion limited, but
some diffusion limitation may occur under some
conditions, including intense exercise, thickening of
the blood-gas barrier, and alveolar hypoxia.
DLCO
DLCO - interpretation
DLCO ↓ by:
Pulmonary vascular diseases
Conditions affecting alveoli
Cardiac diseases
Anaemia
Pregnancy
Recent smoking
DLCO - interpretation
DLCO ↑ by
Polycythaemia
Pulmonary haemorrhage
L to R shunt
Exercise
Blood Flow
The volume of blood passing through the lungs each
minute (Q) can be calculated using the Fick
principle.
This states that the O2 consumption per minute (VO2)
measured at the lungs is equal to the product of blood
flow and A-V concentration gradient of O2.
Blood Flow
• arterial pressure is reduced
(severe hemorrhage,)
• alveolar pressure is raised
(PPV)
Ventilation Perfusion Relationship
V-P ratio
VP in Normal
V-P in disease
TESTS FOR GAS EXCHANGE FUNCTION
1) ALVEOLAR-ARTERIAL O2 TENSION GRADIENT:
 High values at room air is seen in asymptomatic
smokers & chronic. Bronchitis (min. symptoms)

PAO2 = PIO2 – PaCo2

R

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Blood Gases and pH
causes of low arterial Po2, or hypoxemia:
(1) hypoventilation,
(2) diffusion impairment,
(3) shunt, and
(4) ventilation-perfusion inequality
Oxygen cascade
causes of an increased arterial Pco2:
(1) hypoventilation
(2) ventilation-perfusion inequality
 Mechanics of Breathing
Lung Compliance
Compliance is defined as the
volume change per unit of pressure
change across the lung.
To obtain this, we need to know
intrapleural pressure.
Airway Resistance
Airway resistance is the pressure difference between
the alveoli and the mouth per unit of airflow.
Airway resistance is the pressure difference between
the alveoli and the mouth divided by a flow rate.
 Mouth pressure is easily measured with a manometer.
 Alveolar pressure can be deduced from
measurements made in a body plethysmograph.
Airflow Resistance
Closing Volume
The volume of lungs above the RV at which the small
airways close is the closing volume.
In young normal subjects, the closing volume is about
10% of the vital capacity (VC).
 It increases steadily with age and is equal to about
40% of the VC, that is, the FRC, at about the age of 65
years.
 Relatively small amounts of disease in the small
airways apparently increase the closing volume.
pure dead space(1),
a mixture of dead space and alveolar gas (2),
pure alveolar gas (3)
end of expiration, an abrupt increase in N2 (4)
Control of Ventilation
The responsiveness of the chemoreceptors and
respiratory center to CO2 can be measured by having
the subject rebreathe into a rubber bag.
The ventilatory response to hypoxia can be measured
in a similar way if the subject rebreathes from a bag
with a low Po2 but constant Pco2.
Exercise Testing
Exercise testing can be valuable in detecting small
amounts of lung disease.
Peak/Descent/Cough
/Loop

Expl time/FET/
Reproducibility
 Day-1 :
FEV1/FVC :82.51 (108%)
FVC : 2.23 (66%)
FEV1 : 1.84 (71%)

What is the diagnosis ?

: Restrictive Pathology

Day 14 :
FEV1/FVC : 89%
FVC : 3.04 L.(90%)
FEV1 : 2.71 (105%)

: Normal
 Pre-bronchodilator spirograph
shows :
FEV1/FVC : 38.39%(Very low )
FVC : 2.24 (72 % pred.)
FET : 6.12 sec.

Diagnosis ?
Obstructive airway disease
Post- bronchodilatation spirograph
shows:
Δ FVC : 650 ml (29 %)
Δ FEV1 : 290 ml (34%)

What is your final diagnosis ?

Reversible airway obstruction-
Bronchial Asthma
 This patient came with history of
proxysmal cough ,breathlessness
Pre bronchodilator
spirometry findings are:
FEV1/FVC : 86.09 %(normal)
FVC : 1.15 L.(32% of pred.)
Diagnosis :
Restrictive Pathology
But, Post bronchodilator
reading shows:
Δ FVC : 320 ml (28%)
Δ FEV1 : 270 ml (27%)
Now diagnosis is……
How to explain :
Normal FEV1/FVC ratio
Inadequately expiratory time result
in false increase in FEV1 ratio.
Pearl : Obst. Disease,FET
 This spirometry has
 FVC : ↓(1.59 L.49% pred
FEV1/FVC : 62%
Post-bronchodilation
FVC -↓2%
FEV1 -No Change

What is the diagnosis?

-Irreversible airway obstruction
What is the cause of
disproportionate decrease in FVC
Inadequate expiratory time
Loss of lung tissue
 Bullae/Pneumothorax
Associated restrictive pathology
Repeat PFT with long FET
 Red spirograph shows-
FEV1/FVC : Normal (93.75)
FVC : low (38%)

Diagnosis ?
Restrictive disorder
NO , because
Patient has stopped expiring
suddenly as evident by vertical
drop in flow rate
Blue color graph shows :
FEV1/FVC : NORMAL(80%)
FVC : NORMAL (3.70)
FET : NORMAL
NORMAL SPIROMETRY
•PEARL :Vertical drop in expiratory
flow volume loop is unacceptable.
•Inadequately effort will result in false
increase in FEV1/FVC ratio.
 This non smoker female came
with symptoms of cough and
breathlessness following coryza
Spirometric findings are:
FEV1/FVC : 78.42% (normal)
FVC : 60% of Predicted
FEV1 : 65 % of Predicted
What is the diagnosis ?
Restrictive disorder
But,what about the disproportionate
low reading of FEF 25-75 %:
:0.92 L/S.(only 36% of pred.)
Due to small airway disease
(Bronchiolitis Obliterans)
Reduced in FEF 25-75 % with
normal FEV1/FVC ratio.
 Vertical
drop in
expiratory
flow volume
loop

SUDDEN CESSATION
OF EXPIRATION
 Incomplete
flow volume
loop

LEAK AROUND
THE MOUTH
Flattening of
both inspiratory
& expiratory
flow volume
loops

FIXED UPPER AIRWAY

OBSTRUCTION
VARIABLE EXTRA THORACIC AIRWAY
OBSTRUCTION

Flattening of inspiratory loop

VARIABLE INTRA THORACIC
AIRWAY OBSTRUCTION

Flattening of expiratory loop of

flow volume curve
Increased back
extrapolated time (>0.05
sec)

HESITANT START/
TECHNICALLY UNACCEPTABLE
 Large undulations
during early part of
expiration

COUGH/ UNACCEPTABLE
TRACING
 COUGH / ACCEPTABLE

Small undulations in the later part of expiration

DIAPHRAGMATIC PALSY
2

Spirometry in sitting (1) & supine(2) position

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