Basic approach to

PFT interpretation
Dr. Giulio Dominelli
BSc, MD, FRCPC
Kelowna Respiratory and
Allergy Clinic
Disclosures
Received honorarium from Astra Zeneca
for education presentations
Tasked
Asked to talk about the
interpretation of
pulmonary function tests

PFT interpretation is a
HUGE area and we could
easily spend the entire
lecture on any single
component and the
controversies within
them
In order to tackle this,
I will assume a
basic understanding
of the test
mechanics,
measurements,
quality control and
lung physiology that
is used to generate
the data.

Adapted from Pulmonary Function Tests in Clinical practice. Figures 2.1

 Focus

Taking the data to the bedside

Outline
The major focus Brief overview
Before the data Muscle strength
Flow volume loops Methacholine
Spirometry CPET
Lung volumes
Diffusion Examples

Not going to cover:

ABG, Overnight oximetry or sleep studies, walk tests
 Disclaimer
There are many approaches
Thisis the method I take when
approaching interpretation of
PFTs

Find systematic away to

approach

Follow it for each test

Before the data
Who the test is on
Ensure the demographics make sense
Alter your expectations

Who ordered the test and why

GPvs. Specialist
What is their clinical question
Before the test
Did it meet ATS standards
Acceptability and Reproducibility
Will not focus on these criteria
Special comments
Patienteffort
Problems encountered
Smoking history, other clinical symptoms
 Spirometric curves - qualitative
analysis
Flow-Volume Volume-Time

Adapted from Pulmonary Function Tests in Clinical practice. Figures 1.2 and 1.11
Volume-Time curve
Adequacy of the test (6 seconds)
Gives insight into pattern of disease
Obstructive vs. restrictive

http://www.nataliescasebook.com/tag/spirometry
Accessed Sep 205
 Flow-Volume Curve
Ensure adequate test
Free from artefact
Insight into pattern of
disease
Obstructive or
restrictive
Screen for upper
airway obstruction

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.11

 Flow-Volume Curve: Obstruction

Low peak flows

Expiratory limb is
concave or scooped

Total volume is
typically lower

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.18

 Flow-Volume Curve: Restriction
Shape can vary depending on etiology
All lower volume and no concave shape

Parenchymal disease Chest Wall NMD

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.19

Flow-Volume Curve: Upper airway
obstruction
Variable: obstruction comes and goes with
maximal inspiratory or expiratory efforts
Fixed: never changes with forced efforts
Unlike lower airway disease, the
obstruction is present throughout the
expiratory cycle
Ie: not just at low lung volumes
 Flow-Volume Curve: Upper airway
obstruction

Adapted from Pulmonary Function Tests in Clinical practice. Figure 1.20

Upper airway obstruction: Causes

Variable extrathoracic
Dynamic tumors or strictures, vocal cord
paralysis
Variable intrathoracic
Dynamic tumors or strictures and
tracheomalacia
Fixed
Non-dynamic tumors and fibrotic strictures
Looks normal by numbers

Clearly not an acceptable test

Spirometry Quantitative analysis
Controversies
Will not address
LLN vs. fixed cut off for obstruction
Using FVC vs. VC

The absolute cut off of 0.7 is still the most

commonly used and understood
From GOLD
 Obstruction
Grade the severity Assess for
This is per GOLD bronchodilator response

Mild 80% 12%

Moderate 50-79% and
Severe 30-49% 200ml
Very severe <30%
Can be FVC or FEV1
Reversibility
A positive bronchodilator response is
supportive of the diagnosis of asthma
Can also been seen in COPD

False negative
Medications/Caffeine not withheld, specific
antigen, exercise induced
FEF 25-75%
It is not specific for small airway disease
It is highly variable between people and
between test
Does not indicate bronchodilator response

May assist in early or borderline

detection
Examples
Moderate obstruction
without reversibility.
Query cough due to asthma
or COPD?
Mild non-reversible
obstruction.
Consistent with COPD
 Suggestive of a
restrictive disorder

Needs full PFTs

 Lung volumes
Nitrogen washout,
Inert gas dilution
**Plethysmography
By using Boyles law
we can derive the lung
volumes and
capacities that we can
not get from
spirometry
TLC, RV, FRC

Adapted from Pulmonary Function Tests in Clinical practice. Figure 2.3

Lung volumes
Needed to identify

Restriction
Possible etiology
Hyperinflation
Gas trapping
Mixed disorders
Total lung capacity: TLC
Increased Decreased
COPD Restrictive ILD
Acromegaly Chest wall
Athletes (swimmers) NMD
Severity of restriction
Restriction Hyperinflation
Mild 60-80% >120%
Mod. 50-60% Generally dont grade
Severe <50%
Residual Volume
Increased air trapping
Obstructive disorders such as COPD and
asthma

Decreased
Parenchymal restriction
RV/TLC ratio
Restriction
Parenchymal
Normal as symmetrical decrease
Extra-parenchymal
Increased as typically no change in RV
Obstruction
I generally do not look at it, but usually
increased
 FRC insight into lung compliance
Increased
Increases slightly with
age
Emphysema
Due to loss of elastic
recoil
Decreased
Lungfibrosis
Obese
Low ERV
Supine
Bring it together: Disease patterns

Differentiate obstructive subtypes

While both asthma and COPD may have gas
trapping and a high RV/TLC
Asthma should not have hyperinflation
Confirm restriction suspected on
spirometry
Can have low VC due to gas trapping
Disease patterns
Differentiate restrictive subtypes
Parenchymal restriction
Low TLC, RV, but normal RV/TLC
Extra-parenchymal restriction
Low TLC, but normal RV and high RV/TLC
Especially NMD where RV may be very high due to
expiratory muscle weakness
Identify mixed
Low ratio on spirometry, but low TLC
RV can be variable
DLCO
Diffusing capacity of
the lungs for carbon
monoxide measures
the ability of the lungs
to transfer gas from
inhaled air to the red
blood cells in
pulmonary capillaries
Grading severity

>75% normal
60-75% mild
40-60 moderate
<40% severe
DLCO
Decreased Increased
Need to consider the Pulmonary
ddx in the context of hemorrhage
the rest of the PFT Polycythemia
Obstruction
Increased pulmonary
Restriction
blood flow
Isolated DLCO
Mueller, exercise,
pregnancy, supine
position, left to right
shunt
Differential diagnosis

Obstruction Isolated Restriction

Emphysema Anemia ILD

Bronchiolitis CO Pneumonitis

Obstructive ILD Pulmonary NMD

LAM/Sarcoid vasculature
Early ILD Chest wall
DLCO adjustment
Hemoglobin
Polycythemia or anemia can alter the DLCO
Non-linear relationship

CO
Activesmokers can effect the measurement
and can use ABG to adjust
Alveolar volume
DLCO adjustment - VA
Most labs report a DLCO that is corrected for the
measured lung volume (DLCO/VA)
The concept comes from normal subjects who
inhaled a submaximal volume
However, routine use of the DLCO/VA is not
recommended
The correction is not linear and does not give insight
in to the reason for low VA
Incomplete alveolar expansion, diffuse versus localized loss
of alveolar units, and poor alveolar mixing
I only use it to consider extraparenchymal
restriction
Examples
 Scooped flow volume
Very long expiratory phase
Severe non-reversible obstruction, gas trapping, mild gas
exchange..bronchiectasis/ACOS?
Ddx isolated DLCO
Mixed obstructive / restrictive
Severe gas exchange
Likely not just simple COPD
Severe obstruction, hyperinflated, gas trapping, severe
gas exchange
The supplemental tests
Muscle strength

Methacholine
Muscle strength
MIP and MEP
Useful in monitoring
known NMD
In those with
restriction or
dyspnea NYD
Can be seen before
clinical weakness
Muscle strength
Low MIP, normal MEP
Diaphragmatic paralysis
Low MEP, normal MIP
Spinal cord injury below C5
Low MIP can also be seen in gas trapping
Diaphragm at a mechanic disadvantage
MEP <40 predicts ineffective cough
Muscle strength
Supine and upright FVC
Drop in FVC of <10% in normal
Drop of >30% suggests bilateral
diaphragmatic paralysis
Mild-moderate restriction and borderline gas exchange that
overcorrects for Va
?Extra-parenchymal restriction, specifically NMD
Bronchial Challenge test
Used to help in diagnosing or excluding asthma
by provoking bronchoconstriction by controlled
external stimuli
Most commonly methacholine used (M-agonist)
 Test and severity

Adapted from Pulmonary Function Tests in Clinical practice. Figure 4.1

Interpretation
A negative methacholine test is very useful
in ruling out asthma
Very high negative predictive value
False negative: medication and specific Ag
A positive methacholine does not equal
asthma
Must be taken in clinical context
False positive methacholine
Allergic rhinitis without asthma
Smokers/COPD
CHF
Bronchiectasis / CF
Sarcoid
Recent URTI
 A quick word on CPET

Adapted from Pulmonary Function Tests in Clinical practice. Figure 9.2

CPET
An underutilized tool
Determine exercise capacity
Exercise prescription, disability
Identify the cause of exercise impairment
Dyspnea NYD
Select therapy and response
Thoracic surgery and response to PH Rx
Diagnose exercise induced asthma
Reference material
Pulmonary function tests in clinical
practice
DrAltalag, Road and Wilcox
Springer 2009
Interpretative strategies for the lung
function tests
Pellegrinoet al.
Eu. Respir. J. 2005
Special thanks
To all the RTs at KGH
Especially
the PFT department where all my
examples came from
Questions or some more examples
 Certainly looks like asthma
Patient reports previous smoking history
Mild reversible obstruction with gas trapping
Normal diffusion
Consistent with asthma and not COPD
 Not diagnostic of asthma
Certainly severe obstruction, high FRC, borderline diffusion
Asthma, COPD, ACOS
 Not obstructive (post bronchodilator)
Moderate restriction
Severe diffusion, probably PHTN and restriction
Very severe obstruction, hyperinflation, gas trapping and
diffusion
Severe COPD