Pulmonary Function Testing

PULMONARY
FUNCTION
TESTING
Benefits of spirometry
Key to the diagnosis and identification of

obstructive pulmonary conditions
Useful in identifying restrictive lung conditions
Assessment of response to therapy
Pre operative pulmonary evaluation
Encourages adherence to treatment
DISCOVERY OF THE SPIROMETER
Sir John Hutchinson, 1846
Hutchinson J, The Lancet 1846; 1: 630-632

Now we have user friendly
equipment
Spirometry is a simple test to measure the amount
of air a person can breathe out, and the amount of
time taken to do so
A spirometer is a device used to measure how

effectively and how quickly the lungs can be
emptied and filled
Peak Expiratory Flow (PEF)
The maximum flow during the first 10

seconds of forced expiration starting at a
full inspiration
Often measured in L/min, sometimes it will
be expressed as L/sec
Tidal Volume (Vt)
Volume of air that enters and leaves the

lungs during normal breathing
Normal range---500ml
Vital capacity
The volume change at the mouth between

the positions of full inspiration and full
expiration
Normal range----6 litres

Forced Vital Capacity (FVC)
The maximal volume of gas which can be

expired from the lungs during a forced and
complete expiration from a position of full
inspiration
Measured in litres
Forced Expiratory Volume in 1
second (FEV1)
The maximal volume of gas which can be

expired from the lungs in the first second of
a forced expiration from a position of full
inspiration
Measured in litres
Residual volume (RV)
Volume of air remaining in lungs at end of

maximum expiration
Normal range---1.2 L
Functional Residual Capacity (FRC)
Volume of air in the lungs at the end of a normal

expiration
Normal range----2.5-3 L
Total lung capacity (TLC)
Volume of gas in the lungs at the end of

maximum inspiration
Lung reaches TLC when force produced
by respiratory muscles balances elastic
recoil of lungs
Normal range---5-6L
Mid Expiratory Flow Rates
(MMFR or MEFR)
The maximal expiratory flow rate in mid

portion of expiration i.e. 25%to 75%
Regarded as a more sensitive measure of

small airways narrowing than FEV1
Two basic types of pulmonary function
abnormalities are described using the basic
spirometric parameters:Obstructive and
Restrictive
Obstructive Disorders
Airway disorders such as :
Asthma
Chronic Obstructive Pulmonary Disease(COPD)
Bronchiectasis, etc.
Restrictive Disorders
Chest wall
Pleural
Lung parenchymal diseases

Contraindications for spirometry
No apparent absolute contraindications exist
The relative contraindications are
Hemoptysis of unknown origin
Pneumothorax
Unstable cardiovascular status
Recent myocardial infarction upto 1 month
Thoracic and abdominal or cerebral aneurysms.
Nausea, vomiting
Recent eye surgery
Recent surgery of thorax / abdomen
Complications of spirometry
Syncope, dizziness, light headedness

Pneumothorax
Chest pain
Coughing
Bronchospasm
Contraction of infection
SPIROMETRY
Performance Procedures
&
Maneuvers
American Thoracic Society Criteria for
performing Spirometry
Maximal, smooth, and cough free effort
Perform in sitting position
Exhalation time should be 6 seconds
Short acting bronchodilators to be withheld for 4-
6 hours prior to test
Long acting bronchodilators to be withheld for 24
hours prior to test
Do not perform spirometry within 4 to 6 weeks of
lower respiratory tract infection
Pre test requirements
Record the subject’s age, height and weight (wearing light
clothes, without shoes) for the use in calculation of the
reference values
The height should be measured without shoes, and the feet
together, standing as tall as possible with the eyes level
looking straight ahead, using an accurate measuring device
The operator should record the type and dosage of all
medication, no matter what route, and when the drug was
last taken
Ideally the subject shouldbe asked to avoid:
Smoking for 24 hours prior to the test

It is also useful to ask when the patient last smoked a cigarette
Consuming alcohol for at least 4 hours
Vigorous exercise for at least 30 minutes prior to the test
Wearing tight clothes
Eating a substantial meal at least 2 hours prior to tests
Test should be performed when the patient is clinically stable and free
from infection
Drinking fluids containing caffeine for 12 hours prior to testing
The subject should be seated for approximately 5
minutes prior to the tests and should remain seated
throughout the investigations
Should sit upright in a chair with arms and a backrest
Ideally repeat visits should be arranged for
approximately the same time of day. The operator
should be the same and also the equipment
Procedure
Carefully explain the procedure to the

patient
Loosen tight clothing
Remove the nose ring
Ensure that he/she is sitting erect with feet
firmly on the floor
Apply a nose clip to the patient's nose
Remove loose dentures
Measurement of FEV1 and FVC
Place the lips and teeth tightly around the mouthpiece
The patient is instructed to breath in as fully as possible which
should be rapid (full inspiration)
Then to blow out into the equipment as hard and as fast as
possible until no further gas can be exhaled, must be at least 6
seconds and can take upto 15 seconds
The patient should perform a minimum of three attempts
The results reported should be the largest value achieved from
the three technically acceptable tests
The difference between the values should be lessthan 5% or
100 ml
Bronchodilator reversibility
criteria
Increase in baseline FEV1 after bronchodilator

of at least 12% of the baseline value and at least
200 ml
Calculation of % Improvement
FEV1 (post – bronchodilator) – FEV1 (baseline) X 100
FEV1 (baseline)
SPIROMETRY
Interpretation of Results
Spirometry-What to look for?
Look at the Values :

FEV 1, FVC , FEV1/FVC Ratio,
FEF25-75% & PEFR
Normal Absolute Values
FEV 1 : > 80 % predicted
FVC : > 80 % predicted
FEV 1 / FVC Ratio : > 70 %
PEFR : > 80 % predicted

RESTRICTIVE PATTERN
Certain diseases of the lungs, pleura(fibrosis, pleural
effusion), chest wall ( kyphoscoliosis), neuromuscular
disorders (GB syndrome) may prevent full expansion of
the lungs
Appreciable reduction of FVC
Hence FEV1/FVC ratio is normal or high.

Reversibility
Reversibility is an important feature of Bronchial Asthma &
should be taken into account for planning treatment
Spirometry is to be repeated after15-30 minutes after
administration of bronchodialators (Salbutamol 2.5 mg by
nebulizer)
For all practical purposes 12% improvement in FEV1 is
accepted as reversible
FEV1/FVC ratio should not be considered to assess response to
bronchodialators
Parameter Obstructive Restrictive
FEV 1 Reduced Reduced
FVC Normal Reduced
FEV1/FVC Reduced Normal

Pulmonary Function Testing

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PULMONARY

Key to the diagnosis and identification of

Sir John Hutchinson, 1846

Hutchinson J, The Lancet 1846; 1: 630-632

A spirometer is a device used to measure how

The maximum flow during the first 10

Volume of air that enters and leaves the

The volume change at the mouth between

Normal range----6 litres

The maximal volume of gas which can be

The maximal volume of gas which can be

Volume of air remaining in lungs at end of

Volume of air in the lungs at the end of a normal

Volume of gas in the lungs at the end of

The maximal expiratory flow rate in mid

Regarded as a more sensitive measure of

Airway disorders such as :

Chronic Obstructive Pulmonary Disease(COPD)

Lung parenchymal diseases

Syncope, dizziness, light headedness

Smoking for 24 hours prior to the test

Carefully explain the procedure to the

Increase in baseline FEV1 after bronchodilator

Look at the Values :

FEV 1 : > 80 % predicted

FVC : > 80 % predicted

FEV 1 / FVC Ratio : > 70 %

PEFR : > 80 % predicted

Hence FEV1/FVC ratio is normal or high.

FEV 1 Reduced Reduced

FVC Normal Reduced

FEV1/FVC Reduced Normal

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