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الرحیم الرحمن الله بسم
Fariba RezaeetalabAssistant professor ,pulmonologist
Lung Volumes4 Lung Volumes, 3 of which can be measured with simple spirometry.
Tidal Volume (Vt): The volume of air that normally moves into and out of the lungs in one “quiet” breath.
Normal: 5-8 ml/kg (70 kg * 7 ml/kg = 500 ml).
Inspiratory Reserve Volume (IRV): The maximum volume of air that can be inhaled after a normal tidal volume.
Normal: 3,100 mL
Expiratory Reserve Volume (ERV): The volume of air that can be exhaled after a normal tidal volume.
Normal: 1,200 mLResidual Volume (RV): The amount of air remaining in the lung after a maximal exhalation.
Normal: 1,200 mL Cannot be measured with simple spirometery
Lung Volume
Directions for Lung Volume/Capacity Measurements
Tidal Volume (Vt): Breathe normally in and out.
Inspiratory Reserve Volume (IRV): Inhale as much as you can from a normal inhalation.
Expiratory Reserve Volume (ERV): Exhale as much as you can from a normal exhalation..
Residual Volume (RV): This volume cannot be measured directly with simple spirometry.
Slow Vital Capacity (SVC): Take a deep breath in, as deep as you can, and then blow it out slowly until you can’t blow out any more.
Indirect Measurements of RV
The residual volume (and the capacities which have it as a part – FRC & TLC) must be measured indirectly by one of three methods: Helium Dilution – Closed Circuit Method Nitrogen Washout – Open Circuit
Method Body Plethysmography
Lung Volumes / Gas Distribution
Indirect Spirometry
Two basic approaches
Gas dilution
Body plethysmography
Measurements are in Liter or Milliliters Reported at BTPS
Lung Volumes / Gas Distribution
Indirect Spirometry
Required for the determination of RV, FRC and TLC
Most often, indirect spirometry is performed to measure FRC volume
FRC is the most reproducible lung volume and it provides a consistent baseline for measurement
Lung Volumes / Gas Distribution
Gas dilution techniques
All operate on a principle SIMILAR to Boyle’s Law (P1 V1 = P2 V2), which states,
In isothermic conditions, the volume of a gas varies inversely with its pressure
Fractional concentration of a known gas is used instead of its partial pressure
C1 V1 = C2 V2
Lung Volumes / Gas Distribution
Gas dilution techniques
By having a known (or measured) gas concentration at the start and end of the study and a single known volume, the unknown volume can be determined. For example:
V1 = C2 V2
C1
TOTAL LUNG CAPACITY
By applying Boyle’s law (P · V = constant) TLC
• Measured by – body plethysmography– helium dilution– Nitrogen washout – Body plethysmography– mouthpiece obstructed with
shutter– rapid panting chest volume expand and
decompress the air in the lungs
changes in pressure inside the box allow determination of the lungof the lung volume
HELIUM DILUTION
TOTAL LUNG CAPACITY
• Helium dilution- Spirometer of known volume and helium concentration connected to the patient- Closed circuit - Law of conservation of mass
• [He]initial.Vs=[He]final.(Vs+VL)
• Unknown lung volume canbe calculated
[He] [He] initial · Vs =
{H.,.,.H{[[) initial · Vs = [He] final · (Vs + )
RV=TLC-VCFRC=TLC- IC
NITROGEN WASHOUT
Lung Volumes / Gas Distribution
Objectives
Describe the measurement of lung volume using direct and indirect spirometry
Explain two advantages of measuring lung volumes using the body plethysmograph
Lung Volumes / Gas Distribution
Objectives
Calculate residual volume and total lung capacity from FRC and the subdivisions of VC
Identify restriction from measuring lung volumes
Lung Volumes / Gas Distribution
Direct Spirometry
Used to measure all volumes and capacities EXCEPT for RV, FRC and TLC
Lung Volumes / Gas Distribution
Gas dilution techniques
Can only measure lung volumes in communication with conducting airways !!!
Lung Volumes / Gas Distribution
Gas dilution techniques
Obstruction or bullous disease can have trapped, noncommunicating air within the lungs
FRC may be measured as being less than its actual volume
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
The natural volume of nitrogen in the subject’s lungs at FRC is washed out and diluted with 100% oxygen
Test must be carefully initiated from the FRC baseline level
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
All exhaled gas is collected in a Tissot (large volume) spirometer for measurement of its volume
Analyzer in the breathing circuit monitors nitrogen concentrations
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Approximately 3-7 minutes of breathing 100% O2 to wash out N2 from the lungs
If oxygen-induced hypoventilation is a documented problem (as in COPD), a different method of FRC determination is needed
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Test is successfully completed when the N2 levels decrease to become less than 1.5% for at least 3 successive breaths (subjects without obstructive disorders)
Premature discontinuation may occur due to:
System leak Patient unable to continue Tissot spirometer is full
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
The FRC has a N2 concentration of approximately 0.75, based on the atmospheric nitrogen minus CO2 and water vapor at BTPS:
(CAlvN2) = 0.75
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
The final collected volume of exhaled gas in the Tissot spirometer
(VExh)
Has a measurable concentration of N2
(CExhN2)
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
FRC determination is based on the following equation:
VFRC = (CExhN2)(VExh) CAlvN2
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
In the actual FRC determination by this method, the calculation is more complex
Do not get scared !You will not be asked to do
the calculation!
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
The small final concentration of alveolar N2 remaining in the lung needs to be subtracted from the original CalvN2
Deep breath of O2 at the end of the test and slowly exhaled. The end-expiratory CN2 is used as the CFN2 (This volume should not be exhaled into the spirometer)
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
The second correction is the volume of nitrogen released from the body tissues during the washout procedure (body tissue N2 factor or BTN2)
Rages from 30 – 50 ml/minute of the washout procedure (TTest)
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Final Calculation
VFRC = (CExhN2 X (VExh +VD) ) - BTN2 Factor X TTest
CAlvN2 – CFN2
Must be BTPS converted Test can be repeated after 15 minutes (longer if COPD)
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Modern computer-operated pneumotachometer systems do not require collection of total VExh or measurement of the CExhN2
Breath-by-breath CExhN2 and VExh measurements are made
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout Leak
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Criteria for Acceptability
The washout tracing/display should indicate a continually falling concentration of alveolar N2
The test should be continued until the N2 concentration falls to <1.5% for 3 consecutive breaths
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Criteria for Acceptability
Washout times should be appropriate for the subject tested. Healthy subjects should washout N2 completely in 3-4 minutes
The washout time should be reported. Failure to wash out N2 within 7 minutes should be noted
Lung Volumes / Gas Distribution
Open-Circuit Nitrogen Washout
Criteria for Acceptability
Multiple measurements should agree within 10%
Average FRC from acceptable trials should
be used to calculate lung volumes
At least 15 minutes of room-air breathing should elapse between repeated trials, >1 hour for patients with severe obstructive or bullous disease
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
FRC is calculated indirectly by diluting the gas in the lungs at the end-expiration level with a known concentration of helium (an inert gas)
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
FRC
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Procedure
•Spirometer is filled with a known volume of air with added oxygen of 25 – 30%
•A volume of He is added so that a concentration of approximately 10% is achieved
•System volume (spirometer, tubing) and He concentration are measured
Closed-Circuit Helium Dilution
C1 V1 = C2 V2
(C1 initial He concentration)(V1 system volume)
Lung Volumes / Gas Distribution
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Procedure
•The patient breathes through a free-breathing valve that allows either connection to both room air or the rebreathing system
•The patient is switched into the rebreathing system at end-expiration level (FRC)
•The patient rebreathes the gas in the spirometer, until the He concentration falls to a stable level
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
CO2 Absorbed
O2 Added
H2O Absorbed
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
He Concentration
System Volume
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Procedure
•Once the He reaches equilibrium between the spirometer and the patient, the final concentration of He is recorded
•The FRC can then be calculated
FRC
Closed-Circuit Helium Dilution
C1 V1 = C2 V2
Lung Volumes / Gas Distribution
(CIHe)(SV) = (CFHe)(FRC)
FRC = (%HeInitial - %HeFinal) x System volume
%HeFinal
Closed-Circuit Helium Dilution
Volume Corrections
A volume of 100 ml is sometimes subtracted from the FRC to correct loss of He to the blood
The dead space volume of the breathing valve and filter should be subtracted from the FRC
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Criteria for Acceptability
Spirometer tracing should indicate no leaks (detected by a sudden decrease in He), which would cause an overestimation of FRC
Test is successfully completed when He readings change by less than 0.02% in 30 seconds or until 10 minutes has elapsed
Lung Volumes / Gas Distribution
Closed-Circuit Helium Dilution
Criteria for Acceptability
Multiple measurements of FRC should agree within 10%
The average of acceptable multiple measurements should be reported
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Measurement of FRC by body plethysmograph is based on an application of Boyle’s law
P1V1 = P2V2
or
V1 = P2V2
P1
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Unlike gas dilution tests, BP includes both air in communication with open airways as well as air trapped within noncommunicating thoracic compartments
In patients with air trapping, plethysmography lung volumes are usually larger those measured with gas dilution methods
Volume measured is referred to as thoracic gas volume (TGV or VTG)
ATS is recommending term be dropped and changed to “plethysmographic lung volume” (VL, pleth), and “FRC by body plethysmography” or TGV at FRC (FRCpleth)
Lung Volumes / Gas Distribution
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Procedure
•Patient is required to support cheeks with both hands and pant with an open glottis at a rate of 0.5 - 1 Hz (30 – 60 breaths/min)
•BP shutter is suddenly closed at end-expiration prior to inspiration
•Panting is continued for several breaths against closed shutter (no air flow)
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Procedure
•The thoracic-pulmonary volume changes during panting produce air volume changes within the BP cabinet
•Decreases in cabinet volume are an equal inverse response to thoracic volume increase (As thoracic volumes increase with panting inspiration, BP cabinet volume decreases and visa versa)
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Criteria of Acceptability
•Panting maneuver shows a closed loop without drift
•Tracing does not go off the screen
•Panting is 0.5 – 1 Hz
•Tangents should be within 10%
•At least 3 FRCpleth values should agree within 5% and the mean reported
Lung Volumes / Gas Distribution
Body Plethysmography (BP)
Airway Resistance (Raw) and Specific Airway Conductance (SGaw) can be measured simultaneously during open-shutter panting (1.5-2.5 Hz)
Most plethysmographs have built-in pneumotachometers and allow VC maneuvers to be performed during the same testing session
Lung Volumes / Gas Distribution
Single-Breath Nitrogen Washout
Measures Distribution of Ventilation
Closing Volume
Closing Capacity
Lung Volumes / Gas Distribution
SBN2 (SBO2)
Equipment
Lung Volumes / Gas Distribution
SBN2
Procedure Patient exhales to RV
Inspires a VC breath of 100% O2
Patient exhales slowly and evenly (0.3-0.5L/s)
N2 concentration is plotted against volume
Lung Volumes / Gas Distribution
SBN2
Phase I: upper airway gas from anatomical dead space (VDanat), consisting of 100% N2
Phase II: mixed airway gas in which the relative concentrations of O2 and N2 change abrubtly as VDanat volume is expired
SBN2
Phase I: upper airway gas from anatomical dead space (VDanat), consisting of 100% O2
Phase II: mixed airway gas in which the relative concentrations of O2 and N2 change abrubtly as VDanat volume is expired
Lung Volumes / Gas Distribution
SBN2
Phase III: a plateau caused by the exhalation of alveolar gas in which relative O2 and N2 concentrations change slowly and evenly
Phase IV: an abrupt increase in the concentration of N2 that continues until RV is reached
Lung Volumes / Gas Distribution
SBN2% N2 750 – 1250
Is 1.5% or less in healthy adults; up to 3% in older adults
Increased % N2 750 – 1250 is found in diseases characterized by uneven distribution of gas during inspiration or unequal emptying rates during expiration.
Patients with severe emphysema may exceed 10%
Lung Volumes / Gas Distribution
SBN2
Slope of Phase III
Is an index of gas distribution
Values in healthy adults range from 0.5% to 1.0% N2/L of lung volume
Lung Volumes / Gas Distribution
SBN2Closing Volume
The onset of Phase IV marks the lung volume at which airway closure begins
In healthy adults, airways begin closing after 80-90% of VC has been expired, which equates to 30% of TLC
Reported as a percentage of VC
Lung Volumes / Gas Distribution
SBN2Closing Capacity
If RV has been determined, CV may added to it and expressed at Closing Capacity (CC)
CC is recorded as a percentage of TLC
Lung Volumes / Gas Distribution
SBN2Normal Values for CC and CV
________________________________Male Female
CV/%VC 7.7% 8.7%
CC/%TLC 24.8% 25.1%
Lung Volumes / Gas Distribution
SBN2 CV and CC may be increased, indicating
earlier onset of airway closure in:
Elderly patients
Smokers, early obstructive disease of small airways
Restrictive disease patterns in which FRC becomes less than the CV
Congestive heart failure when the caliber of the small airways is compromised by edema
Lung Volumes / Gas Distribution
SBN2
Acceptability Criteria
Inspired and expired VC should be within 5% or 200 ml
The VC during SBN2 should be within 200 ml of a previously determined VC
Expiratory flows should be maintained between 0.3 and 0.5 L/sec.
The N2 tracing should show minimal cardiac oscillations
Lung Volumes
The most significant volumes for evaluating the effects of pulmonary disorders are VC, FRC, RV, and TLC
Lung Volume
Significance/Pathophysiology
Obstructive Pattern
Increase FRC is considered pathologic
FRC values >120% of predicted represent air trapping
Emphysematous changes Obstruction caused by asthma or
bronchitis
Lung volume
Significance/Pathophysiology
Restrictive Pattern FRC, RV and TLC typically decreased
Usually lung volumes are decreased equally
When TLC is <80% a restrictive process is present
RV/TLC is relatively normal
TLC and RV/TLC Ratio
RV/TLC% >35% + Normal TLC =
Air trapping RV/TLC% >35% + >Normal TLC =
hyperinflation
Lung Volume Changes
Patterns of Lung Volume Changes
Volume Restrictive Air Trapping Hyperinflation
TLC N VC NFRC RV RV/TLC% N