Pulmonary Function Test Part 1 PptDr Mona Allangawi

8/6/2019 Pulmonary Function Test Part 1 PptDr Mona Allangawi

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PFT IPFT I 11

Pulmonary function testPulmonary function testPart IPart I

Dr.Mona AllangawiDr.Mona Allangawi

ConsultantConsultant Pulmonary/AllergyPulmonary/Allergy

Hamad General HospitalHamad General Hospital -- HMCHMC


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Pulmonary function test :Pulmonary function test :Group of procedures that measure the function of theGroup of procedures that measure the function of the

lungslungs

1.1. SpirometrySpirometry

2.2. Lung volumesLung volumes

3.3. Gas transferGas transfer

4.4. Bronchial chalengeBronchial chalenge


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IndicationsIndications


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A.DiagnosticA.Diagnostic


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Symptoms:Symptoms:dyspnea, wheezing, orthopnea, cough,dyspnea, wheezing, orthopnea, cough,phlegm production, chest painphlegm production, chest pain

Signs:Signs:

decreased breath sounds, overinflation,decreased breath sounds, overinflation,expiratory slowing, cyanosis, chest deformitory,expiratory slowing, cyanosis, chest deformitory,unexplained cracklesunexplained crackles

Abnormal laboratory tests:Abnormal laboratory tests:

hypoxemia, hypercapnia, polycythemia,hypoxemia, hypercapnia, polycythemia,abnormal chest radiographsabnormal chest radiographs

To measure the effect of disease on pulmonaryTo measure the effect of disease on pulmonaryfunctionfunction


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To screen individuals at risk of having pulmonaryTo screen individuals at risk of having pulmonarydiseasesdiseases

1.1. SmokersSmokers

2.2. Individuals in occupations with exposures toIndividuals in occupations with exposures toinjurious substancesinjurious substances

To assess preoperative riskTo assess preoperative risk

To assess prognosis (lung transplant, etc.)To assess prognosis (lung transplant, etc.)

To assess health status before enrollment inTo assess health status before enrollment instrenuous physical activity programsstrenuous physical activity programs


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B. MonitoringB. Monitoring


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C. Disability/Impairment EvaluationsC. Disability/Impairment Evaluations


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To assess patients as part of a rehabilitationTo assess patients as part of a rehabilitationprogramprogram

MedicalMedical

IndustrialIndustrial

VocationalVocational

To assess risks as part of an insuranceTo assess risks as part of an insurance

evaluationevaluation


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PFT IPFT I 1111

ContraindicationsContraindications


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Hemoptysis of unknown originHemoptysis of unknown origin PneumothoraxPneumothorax

Unstable angina pectorisUnstable angina pectoris

Recent myocardial infarctionRecent myocardial infarction

Thoracic aneurysms

Thoracic aneurysms

Abdominal aneurysmsAbdominal aneurysms

Cerebral aneurysmsCerebral aneurysms

Recent eye surgery (increased intraocular pressureRecent eye surgery (increased intraocular pressureduring forced expiration)during forced expiration)

Recent abdominal or thoracic surgical proceduresRecent abdominal or thoracic surgical procedures

History of syncope associated with forced exhalationHistory of syncope associated with forced exhalation


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PFT IPFT I 1313

Pulmonary function test:Pulmonary function test:

1.1. SpirometrySpirometry

2.2. Lung volumesLung volumes

3.3. Gas transferGas transfer4.4. Bronchial chalengeBronchial chalenge


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What is a spirometry ??What is a spirometry ??SpirometrySpirometry isis aa measuremeasure ofof airflowairflow andand

lunglung volumesvolumes duringduring aa forcedforced expiratoryexpiratory

maneuvermaneuver fromfrom fullfull inspirationinspiration


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How to do it ??How to do it ??


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1.1. Stand or sit up straight (The patient places aStand or sit up straight (The patient places aclip over the nose )clip over the nose )

2.2. Inhale maximallyInhale maximally

3.3. Get a good seal around mouthpiece of theGet a good seal around mouthpiece of thespirometerspirometer

4.4. Blow out as hard as fast as possible andBlow out as hard as fast as possible andcount for at least 6 seconds.count for at least 6 seconds.

5.5. Record the best of three trialRecord the best of three trial

*pt should hold bronchodilator few hrs before the test*pt should hold bronchodilator few hrs before the test


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1. Volume Time Graph 2. Flow1. Volume Time Graph 2. Flow--volume loopsvolume loops


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Volume Time GraphVolume Time Graph

The volume is plotted against the time, it displays

The volume is plotted against the time, it displaysthe expiration.the expiration.


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1.1. FVCFVC2.2. FEVFEV11

3.3. FEVFEV11/FVC/FVC

4.4. FEFFEF2525%%

5.5. FEFFEF7575%%


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Forced Vital Capacity (FVC)Forced Vital Capacity (FVC)The total amount of air expired asThe total amount of air expired asquickly as possible after taking thequickly as possible after taking the

deepest possible breath.deepest possible breath.


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FEV1FEV1 ::

Volume of air which can be forciblyVolume of air which can be forciblyexhaled from the lungs in the firstexhaled from the lungs in the first

second of a forced expiratorysecond of a forced expiratorymaneuver.maneuver.


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PFT IPFT I 2222

FEVFEV11/FVC/FVC

Ratio ofRatio ofFEVFEV11 toto FVCFVC::

It indicates what percentage of the totalIt indicates what percentage of the total FVCFVCwas expelled from the lungs during the firstwas expelled from the lungs during the first

second of forced exhalationsecond of forced exhalationThis value is critically important in theThis value is critically important in thediagnosis of obstructive and restrictivediagnosis of obstructive and restrictive

diseasesdiseases


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FEF25%Amount of air that was forcibly expelled in the firstAmount of air that was forcibly expelled in the first

25% of the total forced vital capacity test.25% of the total forced vital capacity test.

FEF75%FEF75%

The amount of air expelled from the lungs during theThe amount of air expelled from the lungs during the

first (75%) of the forced vital capacity test.first (75%) of the forced vital capacity test.

FEF25%FEF25%--75%75%

The amount of air expelled from the lungs duringThe amount of air expelled from the lungs duringthe middle half of the forced vital capacity test.the middle half of the forced vital capacity test.


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FlowFlow--volume loopsvolume loops


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FlowFlow--volume loopsvolume loops

Is a plot of inspiratoryIs a plot of inspiratoryand expiratory flow inand expiratory flow in

the vertical axis againstthe vertical axis againstvolume in the horizentalvolume in the horizentalaxis, during theaxis, during theperformance ofperformance of

maximally forcedmaximally forcedinspiratory andinspiratory andexpiratory maneuvers.expiratory maneuvers.


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The contour of the loop assists in theThe contour of the loop assists in thediagnosis and localization of airwaydiagnosis and localization of airwayobstruction as different lung disordersobstruction as different lung disordersproduce distinct ,easily recognizedproduce distinct ,easily recognizedpattern.pattern.


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Useful also in assesing acceptability of the manoeuvers:Useful also in assesing acceptability of the manoeuvers:11.. Lack of early peak suggest poor effort.Lack of early peak suggest poor effort.22.. Sudden tailing off of expiration curve suggest that theSudden tailing off of expiration curve suggest that the

patient stopped blowing too earlypatient stopped blowing too early

33.. CoughCough


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PFT IPFT I 2929

Obstructive V/S restrictive lungObstructive V/S restrictive lungdisease ???disease ???


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Common Obstructive Lung DiseasesCommon Obstructive Lung DiseasesAsthmaAsthma

COPDCOPD (chronic bronchitis, emphysema and(chronic bronchitis, emphysema and

the overlap between them).the overlap between them). Cystic fibrosis.Cystic fibrosis.


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--Airflow is reduced because the airways narrow and theAirflow is reduced because the airways narrow and the FEVFEV11 isis

reducedreduced--Spirogram may continue to rise for more thanSpirogram may continue to rise for more than 66 seconds because lungseconds because lungtake longer to emptytake longer to empty--FVCFVC may also be reduced because gas is trapped behind obstructedmay also be reduced because gas is trapped behind obstructedbronchi due to increase in intrathoracic pressure during maneuverbronchi due to increase in intrathoracic pressure during maneuvercompresses airways causing early airway closure and gas trapping butcompresses airways causing early airway closure and gas trapping but

this reduction to a lesser extent thanthis reduction to a lesser extent than FEVFEV11


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FEV1FEV1 80% 80% of predictedof predicted NormalNormalFEV1FEV1 6060--80%80% of predictedof predicted mild obst.mild obst.

FEV1FEV1 4040--60%60% of predictedof predicted moderatemoderate

FEV1 FEV1 40%40% of predictedof predicted severesevere

The cardinal feature isThe cardinal feature is FEV1/FVCFEV1/FVC ratio Ifratio If

the ratio less thanthe ratio less than 7070 consider obstructedconsider obstructed

disease .disease .*Predictors: Sex, Age, Ht*Predictors: Sex, Age, Ht


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Predictors: Sex, Age, Ht ??Predictors: Sex, Age, Ht ??

The measurements are related to the following factors:The measurements are related to the following factors:

AgeAge ::FVC and flow rates decline with age. The value of FVC increases up toFVC and flow rates decline with age. The value of FVC increases up to24 years of age and remain stable to age 35.24 years of age and remain stable to age 35.

HeightHeight ::

All spirometric measurements increase with body weight. It is due to anAll spirometric measurements increase with body weight. It is due to anincrease in number and/or size of alveoli relative to airways, the largerincrease in number and/or size of alveoli relative to airways, the largerlungs are likely to take longer than smaller one.lungs are likely to take longer than smaller one.

SexSex ::Most pulmonary function values are lower in female than maleMost pulmonary function values are lower in female than male..

WeightWeight ::A spirometric results are positively correlated with weight to the extentA spirometric results are positively correlated with weight to the extent

that increased weight means growth or muscle mass. Beyond this (inthat increased weight means growth or muscle mass. Beyond this (inobesity) spirometric values (and lung values specially ERV) decreaseobesity) spirometric values (and lung values specially ERV) decreasewith greater weight.with greater weight.


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Flow volume loop inFlow volume loop in

Obstructive lung diseaseObstructive lung disease


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AsthmaAsthma

PeakPeak expiratoryexpiratory flowflow reducedreducedsoso maximummaximum heightheight ofof thethe looploopisis reducedreduced

AirflowAirflow reducesreduces rapidlyrapidly withwiththethe reductionreduction inin thethe lunglungvolumesvolumes becausebecause thethe airwaysairwaysnarrownarrow andand thethe looploop becomebecomeconcaveconcave

ConcavityConcavity maymay bebe thethe indicatorindicatorofof airflowairflow obstructionobstruction andand maymaypresentpresent beforebefore thethe changechange ininFEVFEV11 oror FEVFEV11/FVC/FVC


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PFT IPFT I 3737

EmphysemaEmphysema

AirwaysAirways maymay collapsecollapse duringduringforcedforced expirationexpiration becausebecause ofofdestructiondestruction ofof thethe supportingsupportinglunglung tissuetissue causingcausing veryveryreducedreduced flowflow at at lowlow lunglungvolumevolume andand aa characteristiccharacteristic(dog(dog--leg)leg) appearanceappearance toto thethe

flowflow volumevolume curvecurve


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PFT IPFT I 3838

ReversibilityReversibility

Improvement inImprovement in FEV1 by 12FEV1 by 12--15% or 200 ml15% or 200 ml in repeatingin repeatingspirometry after treatment withspirometry after treatment withSulbutamol 2.5mg or ipratrobiumSulbutamol 2.5mg or ipratrobiumpromide by nebuliser afterpromide by nebuliser after 1515--3030minutesminutes

Reversibility is a characteresticReversibility is a characteresticfeature of B.Asthmafeature of B.Asthma

In chronic asthma there may beIn chronic asthma there may beonly partial reversibility of theonly partial reversibility of the

airflow obstructionairflow obstruction While in COPD the airflow isWhile in COPD the airflow is

irriversible although some casesirriversible although some casesshowed significant improvement.showed significant improvement.


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Interpretation of PFT

sInterpretation of PFT

sStepStep 11.. LookLook at at thethe FlowFlow--VolumeVolume looploop toto determinedetermine

acceptabilityacceptability ofof thethe test,test, andand looklook forfor upperupper airwayairway

obstructionobstruction patternpattern..

StepStep 22.. LookLook atat thethe FEVFEV11 toto determinedetermine ifif it it isis normalnormal ((

8080%% predicted)predicted)..

StepStep 33.. LookLook atatFVCFVC toto determinedetermine ifif it it isis withinwithin normalnormal

limitslimits (( 8080%%))..

StepStep 44.. LookLook atat thethe FEVFEV11/FVC/FVC ratioratio toto determinedetermine ifif it it isis

withinwithin normalnormal limitslimits (( 7070%%))..


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StepStep 55.. LookLook atatFEFFEF2525--7575%% (Normal(Normal (( 6060%%))

IfIf FEVFEV11,, FEVFEV11/FVC/FVC ratio,ratio, andand FEFFEF2525--7575%% allall areare

normal,normal, thethe patientpatient hashas aa normalnormal PFTPFT..

IfIf bothboth FEVFEV11 andand FEVFEV11/FVC/FVC areare normal,normal, butbut FEFFEF2525--

7575%% isis 6060%% ,then,then thinkthink aboutabout earlyearly obstructionobstruction oror

smallsmall airwaysairways obstructionobstruction..


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IfIf FEVFEV11 8080%% andand FEVFEV11/FVC/FVC 7070%%,, therethere isis

obstructiveobstructive defect,defect, if if FVCFVC isis normal,normal, it it isis purepure

obstructionobstruction.. IfIf FVCFVC 8080%% ,, possibilitypossibility ofof additionaladditional

restrictionrestriction isis therethere..

IfIfFEVFEV11 8080%% ,, FVCFVC 8080%% andand FEVFEV11/FVC/FVC 7070%% ,,

therethere isis restrictiverestrictive defect,defect, getget lunglung volumesvolumes toto confirmconfirm..


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ExamplesExamples


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Mild Obstructive Defect with good response toMild Obstructive Defect with good response to

bronchodilatorbronchodilator

Diagnosis:Diagnosis:B.AsthmaB.Asthma


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AA 6666 year old female complains ofyear old female complains of

cough after dust exposurecough after dust exposure

%Pred%PredRefRefMeasMeas

858522..585822..22FVCFVC

979711..858511..7979FEVFEV11

72728181FEVFEV11/FVC/FVC

828222..232311..8282FEFFEF 2525--7575

10910955..2255..6767PEFPEF


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Normal SpirometryNormal Spirometry


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Flow volume loop suggestive of obstructive diseaseFlow volume loop suggestive of obstructive disease

Spirometry showed Severe Obstructive defect with noSpirometry showed Severe Obstructive defect with no

response to bronchodilatorresponse to bronchodilator

Increased FVC could be because of Airtrapping orIncreased FVC could be because of Airtrapping or

could be combined obstructive and restrictive defect tocould be combined obstructive and restrictive defect to

confirm need to do Lung Volumeconfirm need to do Lung Volume

diagnosis :diagnosis :COPDCOPD


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AA 7575 year old female has a history ofyear old female has a history of

dyspnea and palpitationsdyspnea and palpitations

%Pred%PredRefRefMeasMeas

939322..828222..6262FVCFVC

727211..989811..4545FEVFEV11


202022..202000..4343FEFFEF2525--7575

828255..484844..5050PEFPEF


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MildObstructive defectMildObstructive defect


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Large Airway ObstructionLarge Airway Obstruction


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11.. Fixed obstructionFixed obstruction22..Variable extrathoracicVariable extrathoracic obstructionobstruction

33..Variable intrathoracic obstructionVariable intrathoracic obstruction


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Flow Volume Loop inFlow Volume Loop in

Large Airway ObstructionLarge Airway Obstruction


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PFT IPFT I 5454

Fixed obstructionFixed obstruction1. Post intubation stenosis1. Post intubation stenosis

2. Goiter2. Goiter

3. Endotracheal neoplasms3. Endotracheal neoplasms

4. Bronchial stenosis4. Bronchial stenosis

Maximum airflow isMaximum airflow islimited to a similar extentlimited to a similar extent

in bothin both inspinspiration andiration andexpexpirationiration


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VariableVariable extrextrathoracicathoracic

ObstructionObstruction1. Bilateral and unilateral vocal cord1. Bilateral and unilateral vocal cord

paralysisparalysis

2. Vocal cord constriction2. Vocal cord constriction

3. Reduced pharyngeal cross3. Reduced pharyngeal cross--

sectional areasectional area4. Airway burns4. Airway burns

The obstruction worsens inThe obstruction worsens ininspinspiration because theiration because the

negative pressure narrowsnegative pressure narrowsthe trachea and inspiratorythe trachea and inspiratoryflow is reduced to a greaterflow is reduced to a greaterextent than expiratory flowextent than expiratory flow


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In variableIn variable intrintrathoracicathoracicobstructionobstruction

1.1. TracheomalaciaTracheomalacia2. Polychondritis2. Polychondritis

3. Tumors of the lower trachea3. Tumors of the lower trachea

or main bronchus.or main bronchus.The narrowing is maximal inThe narrowing is maximal inexpexpiration because ofiration because ofincreased intrathoracicincreased intrathoracicpressure compressing thepressure compressing the

airway.airway.The flow volume loop shows aThe flow volume loop shows agreater reduction in thegreater reduction in the

expiratoryexpiratory phasephase


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Small Airways obstructionSmall Airways obstruction

DiseasesDiseases affectingaffecting primarilyprimarily thethe smallsmall (peripheral)(peripheral)airwaysairways cancan bebe extensiveextensive yetyet notnot affectaffect thethe FEVFEV11(e(e..gg..earlyearly COPD,COPD, interstitialinterstitial granulomatousgranulomatous disorders)disorders)..

SmallSmall airwaysairways statusstatus isis reflectedreflected byby thethe FEFFEF2525--7575%%(mid(mid--rangerange flow),flow), bestbest determineddetermined fromfrom thethe flowflow--volumevolume looploop..

SomeSome patientspatients havehave normalnormal spirometryspirometry withwith thetheexceptionexception ofof aa reducedreduced FEFFEF2525--7575%%,, thisthis isis suggestivesuggestiveofof possiblepossible smallsmall airwaysairways dysfunctiondysfunction andand potentiallypotentiallyearlyearly obstructionobstruction..


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ExampleExample


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AA 3838 year old female complains ofyear old female complains of

wheezing on exertionwheezing on exertion

%Pr%Preedd

RefRefMeasMeas

10310333..545433..6666FVCFVC

838322..777722..3030FEVFEV11


515144..202022..1515FEFFEF2525--7575

383866..252522..3939PEFPEF


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Flow volume loop suggests a fixed upperFlow volume loop suggests a fixed upperairway obstructionairway obstruction


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Effect of Smoking:Effect of Smoking: Smoking in patients with COPD is associatedSmoking in patients with COPD is associated

with decline inwith decline in FEV1 of90FEV1 of90--150 mL/year150 mL/year

Smoking cessation is (associated withSmoking cessation is (associated withincrease inincrease in FEV1FEV1 for first year) followed withfor first year) followed witha decline of only 30 mL/yeara decline of only 30 mL/year


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Restrictive Lung DiseasesR

estrictive Lung Diseases


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A. Intrinsic Restrictive Lung DisordersA. Intrinsic Restrictive Lung Disorders

1.1. SarcoidosisSarcoidosis

2.2. Idiopathic pulmonary fibrosisIdiopathic pulmonary fibrosis

33.. Interstitial pneumonitisInterstitial pneumonitis

44.. TuberculosisTuberculosis

55.. Pnuemonectomy (loss of lung)Pnuemonectomy (loss of lung)

66.. PneumoniaPneumonia


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C.C. Neuromuscular Restrictive LungNeuromuscular Restrictive LungDisordersDisorders

1.1. Generalized WeaknessGeneralized Weakness malnutritionmalnutrition

2.2. Paralysis of the diaphragmParalysis of the diaphragm

3.3. Myasthenia GravisMyasthenia Gravis

4.4. Muscular DystrophyMuscular Dystrophy

5.5. PoliomyelitisPoliomyelitis

6.6. Amyotrophic Lateral SclerosisAmyotrophic Lateral Sclerosis


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Full expantion of the lungFull expantion of the lungis limited and thereforeis limited and thereforethethe FVCFVC is reducedis reduced

FEVFEV11 may be reducedmay be reducedbecause the stiffness ofbecause the stiffness of

fibrotic lungs increasesfibrotic lungs increasesthe expiratory pressurethe expiratory pressure

FEVFEV11/FVC/FVC will be Normalwill be Normalor Increasedor Increased

*if you suspect restrictive*if you suspect restrictivepattern you must checkpattern you must checkTLCTLC


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Flow volume loop inFlow volume loop in

Restrictive lung diseaseRestrictive lung disease


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Flow volume loop inFlow volume loop inRestrictive lung diseaseRestrictive lung disease :: Full lung expantion isFull lung expantion is

prevented by fibrotic tissue inprevented by fibrotic tissue inthe lung parenchyma and thethe lung parenchyma and theFVCFVC is reduced .is reduced .

Elastic recoil may increased byElastic recoil may increased byfibrotic tissue lead to increasefibrotic tissue lead to increasethe airflowthe airflow

BothBoth FEV1FEV1 andand FVCFVC may bemay bereduced because the lungs arereduced because the lungs aresmall and stiff ,but the peaksmall and stiff ,but the peakexpiratory flow may beexpiratory flow may be

preserved or even higher thanpreserved or even higher thanpredicted leads to tall,narrowpredicted leads to tall,narrowand steep flow volume loop inand steep flow volume loop inexpiratory phase.expiratory phase.


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ExampleExample


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Mild restrictive defect suggested by reduced in FVCMild restrictive defect suggested by reduced in FVCwith normal to high FEV1/FVCwith normal to high FEV1/FVC

Need lung volume and diffusion capacity to assess ifNeed lung volume and diffusion capacity to assess ifit is intrinsic or extrinsic typeit is intrinsic or extrinsic type


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PFT IPFT I 7676

Obstructive & restrictive defectsObstructive & restrictive defects

ParameterParameter ObstructionObstruction RestrictionRestrictionFEVFEV11 ReducedReduced ReducedReduced

FVCFVC NormalNormal ReducedReduced

FEVFEV11/FVC/FVC ReducedReduced NormalNormal


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PFT IPFT I 7777

Acceptability andReproducibilityAcceptability andReproducibility

CriteriaCriteria


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Acceptability CriteriaAcceptability Criteriafree from artifacts:free from artifacts: Cough or glottis closure during the first second ofCough or glottis closure during the first second of

exhalationexhalation Eary termination or cutoffEary termination or cutoff Variable effortVariable effort

LeakLeak Obstructed mouthpieceObstructed mouthpiece Have good startsHave good starts Have a satisfactory exhalationHave a satisfactory exhalation 6 s of exhalation6 s of exhalation


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PFT IPFT I 7979

R

eproducibility CriteriaR

eproducibility CriteriaAfter 3 acceptable spirograms been obtainedAfter 3 acceptable spirograms been obtained Are the two largest FVC within 0.2 L of each other?Are the two largest FVC within 0.2 L of each other?

Are the two largest FEV1 within 0.2 L of each other?Are the two largest FEV1 within 0.2 L of each other?

If both of these criteria are met, the test session mayIf both of these criteria are met, the test session maybe concluded.be concluded.

If both of these criteria are not met, continue testingIf both of these criteria are not met, continue testing

until Both of the criteria are met with analysis ofuntil Both of the criteria are met with analysis ofadditional acceptable spirograms; OR a total of eightadditional acceptable spirograms; OR a total of eighttests have been performedtests have been performed


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Acceptability of the testAcceptability of the test


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Early Glottic Closure

Normal

Poor EffortCough


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ExampleExample


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1.What is the defect?1.What is the defect?


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Mild obstructive defect with good response toMild obstructive defect with good response tobronchodilatorbronchodilator

DiagnosisDiagnosisB.AsthmaB.Asthma

Documents

Pulmonary Function Test Part 1 PptDr Mona Allangawi