What exactly are PFTs?

• The term encompasses a wide variety of objective

methods to assess lung function. (Remember that the
primary function is gas exchange).

• Examples include:
– Spirometry
– Pulse oximetry
– Blood gases
– Lung volumes by helium dilution or body plethysmography
– Exercise tests
– Diffusing capacity
– Bronchial challenge testing
 Spirometry
• Measurement of the pattern of air
movement into and out of the lungs during
controlled ventilatory maneuvers.
• Often done as a maximal expiratory
maneuver
 Importance
• Patients and physicians have inaccurate
perceptions of severity of airflow
obstruction and/or severity of lung disease
by physical exam
• Provides objective evidence in identifying
patterns of disease
Silhouette of Hutchinson
Performing Spirometry

From
Chest,
2002
 Indications
• Detect disease
• Evaluate extent and monitor course of
disease
• Evaluate treatment
• Measure effects of exposures
• Assess risk for surgical procedures
 contraindications
• Chest or abdominal pain of any cause
• Oral or facial pain exacerbated by
mouthpiece
• Stress incontinence
• Dementia or confused state
• Within one month of Myocardial Infarction
 To be avoided
• Smoking- 1 hour
• Alcohol- 4 hour
• Vigorous exercise -30 minutes
• Large meal – 2 hour
• Wearing tight clothes
 Preparation
• Tests should be performed when patients are
clinically stable and free from respiratory infection
• Patients should not have taken:
 inhaled short-acting bronchodilators in the
previous six hours
 long-acting bronchodilator in the previous 12
hours
 sustained-release theophylline in the previous
24 hours
Volume Measuring Spirometer
Flow Measuring Spirometer
Desktop Electronic Spirometers
Small Hand-held Spirometers
 The Airways
• Conducting zone: no
gas exchange occurs
– Anatomic dead
space
• Transitional zone:
alveoli appear, but are
not great in number
• Respiratory zone:
contain the alveolar
sacs
Weibel ER: Morphometry of the Human
Lung. Berlin and New York: Springer-
Verlag, 1963
From
Netter
Atlas of
Human
Anatomy,
1989
Lung Volumes

• 4 Volumes
• 4 Capacities
IRV – Sum of 2 or
IC
more lung
VC
TV volumes
TLC
ERV
FRC
RV RV
Tidal Volume (TV)
• Volume of air
inspired and
expired during
IRV normal quiet
IC
VC
breathing
TV
TLC
ERV
FRC
RV RV
Inspiratory Reserve Volume (IRV)

• The maximum
amount of air
that can be
IRV inhaled after a
IC
VC
normal tidal
TV
TLC volume
inspiration
ERV
FRC
RV RV
Expiratory Reserve Volume (ERV)

• Maximum
amount of air
that can be
IRV exhaled from
IC
VC
the resting
TV
TLC expiratory level
ERV
FRC
RV RV
Residual Volume (RV)
• Volume of air
remaining in the
lungs at the end
IRV of maximum
IC
VC
expiration
TV
TLC
ERV
FRC
RV RV
Vital Capacity (VC)
• Volume of air that
can be exhaled
from the lungs
IRV after a maximum
IC inspiration
VC
TV • FVC: when VC
TLC
exhaled forcefully
ERV
• SVC: when VC is
FRC
exhaled slowly
RV RV
• VC = IRV + TV +
ERV
 Predicted Normal Values

Affected by:
 Age
 Height
 Sex
 Ethnic Origin
Terminology

• Forced vital capacity

(FVC):
– Total volume of air that can
be exhaled forcefully from
TLC
– The majority of FVC can be
exhaled in <3 seconds in
normal people, but often is
much more prolonged in
obstructive diseases
– Measured in liters (L)
 FVC
• Interpretation of % predicted:
– 80-120% Normal
– 70-79% Mild reduction
– 50%-69% Moderate reduction
– <50% Severe reduction

FVC
Terminology
• Forced expiratory volume
in 1 second: (FEV1)
– Volume of air forcefully
expired from full inflation
(TLC) in the first second
– Measured in liters (L)
– Normal people can exhale
more than 75-80% of their
FVC in the first second;
thus the FEV1/FVC can be
utilized to characterize
lung disease
 FEV1
• Interpretation of % predicted:
– >75% Normal
– 60%-75% Mild obstruction
– 50-59% Moderate obstruction
– <49% Severe obstruction

FEV1 FVC
Terminology

• Forced expiratory flow 25-

75% (FEF25-75)
– Mean forced expiratory flow
during middle half of FVC
– Measured in L/sec
– May reflect effort
independent expiration and
the status of the small
airways
– Highly variable
– Depends heavily on FVC
 FEF25-75
• Interpretation of % predicted:
– >60% Normal
– 40-60% Mild obstruction
– 20-40% Moderate obstruction
– <10% Severe obstruction
 Standard Spirometric Indicies
• FEV1 - Forced expiratory volume in one second:
The volume of air expired in the first second of
the blow
• FVC - Forced vital capacity:
The total volume of air that can be forcibly
exhaled in one breath
• FEV1/FVC ratio:
The fraction of air exhaled in the first second
relative to the total volume exhaled
 Criteria for Normal
Post-bronchodilator Spirometry

• FEV1: % predicted > 80%

• FVC: % predicted > 80%

• FEV1/FVC: > 0.7

 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 N↑
– TLC nl or ↑ – TLC ↓
SPIROMETRY

Flow Volume
 Flow Volume Curve
• Standard on most desk-top spirometers
• Adds more information than volume
time curve
• Less understood but not too difficult to
interpret
• Better at demonstrating mild airflow
obstruction
 Flow Volume Curve

Maximum
expiratory flow
(PEF)

Expiratory
flow rate
L/sec

FVC RV
TLC

Inspiratory
flow rate
L/sec

Volume (L)
 Flow-Volume Loop
• Illustrates maximum
expiratory and
inspiratory flow-
volume curves
• Useful to help
characterize disease
states (e.g.
obstructive vs.
restrictive)

Ruppel GL. Manual of Pulmonary Function Testing, 8th

ed., Mosby 2003
 Normal Trace Showing FEV1 and
FVC

5 FVC
Volume, liters

4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1

1 2 3 4 5 6

Time, seconds
Reproducibility - Quality of Results

Volume, liters

Time, seconds

Three times FVC within 5% or 0.1 litre (100 ml)

 Spirogram Patterns

• Normal

• Obstructive

• Restrictive

• Mixed Obstructive and Restrictive

SPIROMETRY

OBSTRUCTIVE
DISEASE
Spirometry: Obstructive Disease

5
4
Volume, liters

Normal
3
FEV1 = 1.8L
2
FVC = 3.2L Obstructive
1
FEV1/FVC = 0.56

1 2 3 4 5 6
Time, seconds
 Flow Volume Curve Patterns
Obstructive and Restrictive

Obstructive Severe obstructive Restrictive

Expiratory flow rate

Expiratory flow rate

Expiratory flow rate

Volume (L) Volume (L) Volume (L)

Reduced peak flow, Steeple pattern, Normal shape,

scooped out mid- reduced peak flow, normal peak flow,
curve rapid fall off reduced volume
 Bronchodilator Reversibility Testing

• Provides the best achievable FEV1

(and FVC)
• Helps to differentiate COPD from
asthma
Must be interpreted with clinical
history - neither asthma nor COPD
are diagnosed on spirometry alone
 Bronchodilator Reversibility
Testing in COPD
Spirometry
•FEV1 should be measured (minimum twice,
within 5%) before a bronchodilator is given
•The bronchodilator should be given by
metered dose inhaler through a spacer device
or by nebulizer to be certain it has been
inhaled
•The bronchodilator dose should be selected to
be high on the dose/response curve
 Bronchodilator Reversibility Testing
in COPD
•An increase in FEV1 that is both greater
than 200 ml and 12% above the pre-
bronchodilator FEV1 (baseline value) is
considered significant
•It is usually helpful to report the absolute
change (in ml) as well as the % change from
baseline to set the improvement in a clinical
context
 Figure 5.1-6.
Bronchodilator
Reversibility
Testing in COPD

GOLD
Report (2006)
SPIROMETRY

RESTRICTIVE
DISEASE
Spirometry: Restrictive Disease

5 Normal
Volume, liters

3
Restrictive FEV1 = 1.9L
2
FVC = 2.0L
1
FEV1/FVC = 0.95

1 2 3 4 5 6
Time, seconds
 Flow Volume Curve Patterns
Obstructive and Restrictive

Obstructive Severe obstructive Restrictive

Expiratory flow rate

Expiratory flow rate

Expiratory flow rate

Volume (L) Volume (L) Volume (L)

Reduced peak flow, Steeple pattern, Normal shape,

scooped out mid- reduced peak flow, normal peak flow,
curve rapid fall off reduced volume
 Mixed Obstructive and Restrictive

Normal
Volume, liters

FEV1 = 0.5L
Obstructive - Restrictive FVC = 1.5L

FEV1/FVC = 0.30

Time, seconds
Restrictive and mixed obstructive-restrictive are difficult to diagnose by
spirometry alone; full respiratory function tests are usually required
(e.g., body plethysmography, etc)
 Spirometry - Quality Control
• Most common cause of inconsistent
readings is poor patient technique
 Sub-optimal inspiration
 Sub-maximal expiratory effort
 Delay in forced expiration
 Shortened expiratory time
 Air leak around the mouthpiece
• Subjects must be observed and
encouraged throughout the procedure
 Troubleshooting

Examples - Unacceptable Traces

Unacceptable Trace - Poor Effort

Volume, liters
Normal
Variable expiratory effort
Inadequate sustaining of effort

May be accompanied by a slow start

Time, seconds
Unacceptable Trace – Stop Early

Normal
Volume, liters

Time, seconds
Unacceptable Trace – Slow Start

Normal
Volume, liters

Time, seconds
Unacceptable Trace - Coughing

Normal
Volume, liters

Time, seconds
Unacceptable Trace – Extra Breath

Normal
Volume, liters

Time, seconds
 EXAMPLE 1
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 4.0 L 3.2 3.2

FVC%(O/P) 80% 80%

FEV1 3.7L 2.9 2.9 +0%- 0ml

FEV1%(O/P) 78% 78%

FEV1/FVC% 90% 90%

PEF 3.51L/S 4.22L/S

 EXAMPLE -2
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 2.8L 0.6

FVC%(O/P) 22%

FEV1 2.75L 0.5

FEV1%(O/P) 18.18%

FEV1/FVC% 84%

PEF 5.3L/S 1.6

 EXAMPLE 2 cont
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 2.8L 0.6 1.6L

FVC%(O/P) 22% 57%

FEV1 2.75L 0.5 1.0L +100%-500ml

FEV1%(O/P) 18.18% 36.3%

FEV1/FVC% 84% 63%

PEF 5.3L/S 1.6 4.8

 EXAMPLE 3
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 2.60L 1.60 1.63

FVC%(O/P) 62% 63%

FEV1 2.17L 1.32 1.34 1.5%-20ml

FEV1%(O/P) 61% 62%

FEV1/FVC% 83% 82%

PEF 5.85L/S 5.34 4.56

 EXAMPLE 4
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 2.3L 1.8 1.8

FVC%(O/P) 78% 78%

FEV1 1.95L 0.75 0.75 +0-0ml

FEV1%(O/P) 38% 38%

FEV1/FVC% 41% 41%

PEF 3.10L/s 1.30L/S 1.34L/S

 EXAMPLE 5
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 3.22L 1.69 1.82

FVC%(O/P) 52% 56%

FEV1 2.50L 1.15 1.19 +3%

FEV1%(O/P) 46% 48%

FEV1/FVC% 68% 66%

PEF 7.17L/S 4.48 4.41

 EXAMPLE 6
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 2.75L 1.1 1.5

FVC%(O/P) 40% 54%

FEV1 2L 0.9 1.0 +11%-100ml

FEV1%(O/P) 31% 46%

FEV1/FVC% 81% 66%

PEF 3.7L/s 1.00L/s 3.20L/s

 EXAMPLE 7
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 3.2L 1.54 2.3

FVC%(O/P) 48% 71%

FEV1 2.75L 0.95 1.94 +104%-

990ml
FEV1%(O/P) 34.5% 72%

FEV1/FVC% 61% 69%

PEF 4.50L/s 3L/s 3.70L/s

 EXAMPLE 8
TEST PREDICTE BROCHODILATOR CHANGE
D
BEFORE AFTER

FVC 3.2 L 2.55 2.75

FVC%(O/P) 79% 86%

FEV1 2.75L 1.95 2.3 +18%-

350ml
FEV1%(O/P) 70% 84%

FEV1/FVC% 76% 83%

PEF 4.5L/s 4.00L/s 4.40L/s

gowri