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Visit us at www.drsarma.in. Dr. R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician & Chest Specialist E mail: sarma.rvsn@gmail.com 3760 9226 or 2766 0593 93805 21221 or 98940 60593. Pulmonary Function Tests Ventilatory Function – Spirometry . Clinical Applications. LUNG FUNCTION TESTS.

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visit us at www drsarma in
Visit us at www.drsarma.in

Dr. R.V.S.N.Sarma., M.D., M.Sc.,

Consultant Physician & Chest Specialist

E mail: sarma.rvsn@gmail.com

3760 9226 or 2766 0593

93805 21221 or 98940 60593

lung function tests
LUNG FUNCTION TESTS
  • Tests of Ventilation
  • Tests of Diffusion
  • Tests of Perfusion
  • Tests for V-P Mismatch
lung function tests4
LUNG FUNCTION TESTS
  • Tests of Ventilation
  • Tests of Diffusion
  • Tests of Perfusion
  • Tests for V-P Mismatch
function of ventilation
Function of Ventilation
  • Air Exit – Airways, Bronchomotor tone, Secretions, Thoracic muscles etc
  • Air Entry – Expansion of lungs – Functioning lung volume, its elastic nature, Lung compliance
  • ‘Air Out’ Problem – Obstructive Diseases
  • ‘Air In’ problem – Restrictive Diseases
  • Both Air Out and In - Combined
spirometry
Spirometry

Objectives

  • To detect Obstructive Airway Diseases
  • To quantify the severity of obstruction.
  • To assess response to IBD.
  • To identify Restrictive Lung Diseases.
  • To identify flow-volume loop patterns
  • To understand the clinical relevance.
peak flow meter
PEAK FLOW METER

Diagnosis of ASTHMA or COPD can be

confirmed by demonstrating the presence

of airway obstruction using Spirometry.

pefr pros and cons
PEFR - Pros and Cons
  • Advantages
    • With in 1 to 2 minutes,
    • Inexpensive (meter costs less than Rs.1000)
    • Simple, useful for frequent follow up use
  • Disadvantages
    • Very much effort dependent
    • Insensitive to small changes
    • Small airways cannot be assessed
    • Large inter & intra subject variation;↓accurate
spirometry pros and cons
Spirometry - Pros and Cons
  • Advantages
    • Evaluates smaller as well as larger airways
    • Relatively easy to use and maintain
    • Reversibility can be tested with IBD and steroids
    • Diagnostic as well as management assessments
  • Disadvantages
    • Costs about 50,000 + computer and printer
    • Takes time to perform – 10 to 15 minutes
    • Requires training – at least one day course
spirometry maneuver
Spirometry Maneuver

In single breath test

  • A few normal tidal respirations
  • Then deeeeep inspiration
  • Momentary breath holding
  • Very forced and fast expiration
    • As hard and as fast as he/she can blow out
  • Then deep, quick and full inspiration
  • Repeat at least 3 times – take the best
reproducibility of spirometry
Reproducibility of Spirometry
  • Adequate explanation to the patient
  • Demonstrating the steps one by one
  • Encouraging the patient to give best effort
  • Taking at least 3 and usually 5 attempts
  • Selecting the best effort
  • Cough and severe dyspnoea may interfere
  • Not like ECG – Results depend on effort
spirometry results
Spirometry Results
  • FVC Forced Vital Capacity
  • FEV1 Forced Expiratory Volume in the first second
  • FEV1/FVC Ratio of the above two
  • PEFR Peak Expiratory Flow Rate
  • FET Forced Expiratory Time
slide17

Normal

Flow-Volume

Volume-Time

Test Values

spirometry results18
Spirometry Results
  • FVC Forced Vital Capacity
  • FEV1 Forced Expiratory Volume in the first second
  • FEV1/FVC Ratio of the above two
  • PEFR Peak Expiratory Flow Rate
  • FET Forced Expiratory Time
spirometry normal values
Spirometry Normal Values
  • There are no fixed ‘Normal’ values
  • Dependent on age, sex, height, weight, ethnicity
  • Observed value expressed as % of predicted value
  • FVC Normal if > 80% of predicted
  • FEV1 Normal if > 80% of predicted
  • FEV1/FVC At least 75%
  • PEFR Normal if > 80% of predicted
  • FET Less than 4 seconds
the four square game
The Four Square Game

FEV1 NORMAL

80%

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game21
The Four Square Game

FEV1 NORMAL

Normal Lungs

FEV1÷FCV is N

80%

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game22
The Four Square Game

FEV1 NORMAL

80%

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game23
The Four Square Game

FEV1 NORMAL

Restrictive Disease

FEV1÷FCV is High

80%

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game24
The Four Square Game

FEV1 NORMAL

80%

Combined Obs+Res

FEV1÷FCV is N or L

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game25
The Four Square Game

FEV1 NORMAL

Restrictive Disease

FEV1÷FCV is High

Normal Lungs

FEV1÷FCV is N

80%

Combined Obs+Res

FEV1÷FCV is N or L

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game26
The Four Square Game

FEV1 NORMAL

Air Entry Problem

Lungs ↓ expansion

Normal Air

Entry & Exit

80%

Air Exit Problem

Airways choked

Both Air Entry &

Air Exit Problem

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

the four square game27
The Four Square Game

FEV1 NORMAL

Restrictive Disease

FEV1÷FCV is High

Normal Lungs

FEV1÷FCV is N

80%

Combined Obs+Res

FEV1÷FCV is N or L

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

millers prediction quadrants
Millers Prediction Quadrants

100%

Air Entry is reduced

Restrictive Disease

FEV1÷FCV is High

Air In and Out N

Normal Lungs

FEV1÷FCV is N

FEV1 NORMAL

90%

90%

100%

60%

70%

80%

Both Air In & Out ↓↓

Combined Obs+Res

FEV1÷FCV is N or L

Air Exit is chocked

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

70%

60%

FVC < 80% Pred.

FVC NORMAL

algorithm for diagnosis
Algorithm for Diagnosis

FVC

FVC > 80%

FVC < 80%

FEV1 > 80%

FEV1 < 80%

FEV1 > 80%

FEV1 < 80%

Normal PFT

Obstructive

Restrictive

Combined

IBD

Reversible

Irreversible

Extra-pulmonary

Pulmonary

normal airways and lungs
Normal Airways and Lungs
  • FVC > 80%
  • FEV1 > 80%
  • FEV1÷FCV > 75%
  • PEFR > 80%
  • FET <4 sec
  • Air Entry Normal
  • Air Exit Normal

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

obstructive airways disease
Obstructive Airways Disease
  • Bronchial Asthma – Reversible Airway obs.
  • Chronic bronchitis – Irreversible with IBD
  • Emphysema – Irreversible with IBD
  • Bronchiectasis – Airway rigidity
  • Cystic Fibrosis
  • Allergic bronchopulmonary Aspergillosis
  • Bronchiolitis
obstructive airways disease34
Obstructive Airways Disease
  • FVC > 80%
  • FEV1 < 80%
  • FEV1÷FCV < 75%
  • PEFR < 80%
  • FET >4 sec
  • Air Entry Normal
  • Air Exit Problem

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

obstructive airways disease pft
Obstructive Airways Disease - PFT

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

obstructive airways mild
Obstructive Airways Mild

Bronchial Asthma

bronchiectasis obstructive
Bronchiectasis (Obstructive)

UNILATERAL

BRONCHOGRAM - BIL

obstructive lung diseases
Obstructive Lung Diseases

ABPA

CYSTIC FIBROSIS

upper airway obstruction
Truncation of flow loop

Expiratory – Intra Thoracic

Inspiratory –Extra Thoracic

Both – Fixed Obstruction

Tumour

Tracheal stenosis

Tracheal FB

Vocal Chord Dysfunction

Upper Airway Obstruction
restrictive lung diseases
Restrictive Lung Diseases
  • Sarcoidosis
  • Tuberculosis – (Fibrocaseous)
  • Interstitial Lung Disease - ILD
  • Idiopathic pulmonary fibrosis - IPF
  • Pneumoconiosis
  • Drug- or radiation-induced lung disease
  • Pneumonectomy
extrinsic restrictive diseases
Extrinsic Restrictive Diseases
  • Kyphosis, Scoliosis
  • Ankylosing Spondylitis
  • Massive Pleural effusion
  • Pregnancy, Obesity, Ascites
  • Rib fractures
  • Neuromuscular disorders
restrictive lung disease
FVC < 80%

FEV1 > 80%

FEV1÷FCV > 75%

PEFR > 80%

FET <4 sec

Air Entry Problem

Air Exit Normal

Restrictive Lung Disease

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

restrictive lung disease pft
Restrictive Lung Disease - PFT

ILD or IPF

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

restrictive lung disease ild51
Restrictive Lung Disease - ILD

RETICULAR PERIPHERIES

restrictive lung disease ild52
Restrictive Lung Disease - ILD

HRCT Chest

X-RAY CHEST - ILD

restrictive lung diseases53
Restrictive Lung Diseases

RETICULO-NODULAR

SARCOIDOSIS

combined obstructive restrictive
Combined Obstructive + Restrictive
  • FVC < 80%
  • FEV1 < 80%
  • FEV1÷FCV < 75%
  • PEFR < 80%
  • FET >4 sec
  • Air Entry Problem
  • Air Exit Problem

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

combined obstructive restrictive55
Combined Obstructive + Restrictive

FEV1 is LOW

FVC is Normal

FEV1 ÷ FVC is < 75%

other patterns
Other Patterns

FIXED OBSTRUCTION

other patterns58
Other Patterns

COUGH

EXTRA THORACIC

case 1
Case 1

Man, aged 28, 172cm, 71kg

Non smoker, Cough 3 M

case 160
Case 1

IBD Good Response

Man, aged 28, 172cm, 71kg

Non smoker, Cough 3 M

Dx : Bron Asthma - Rev

case 2
Case 2

Woman, 48 y, 155cm, 47 kg

Non smoker, Dysp., CP

case 262
Case 2

Woman, 48 y, 155cm, 47 kg

Non smoker, Dysp., CP

Diagnosis : # Ribs 5,6,7,8

case 3
Case 3

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

case 364
Case 3

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

Diagnosis : Normal PFT

case 4
Case 4

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.

case 466
Case 4

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.

FB in the UAW

case 5
Case 5

Woman, 29 y, 160cm, 41 kg

Had ATT, Dysp G3, Wheeze

case 568
Case 5

Woman, 29 y, 160cm, 41 kg

Had ATT, Dysp G3, Wheeze

Diagnosis : TB + ABPA

case 6
Case 6

Man, aged 58, 165cm, 51kg

Smoker 16yr, Severe Dysp.

case 670
Case 6

IBD NO Response

Man, aged 68, 165cm, 51kg

Smoker 16yr, Severe Dysp.

DX :COPD- Irreversible

the four square game71
The Four Square Game

FEV1 NORMAL

Restrictive Disease

FEV1÷FCV is High

Normal Lungs

FEV1÷FCV is N

80%

Combined Obs+Res

FEV1÷FCV is N or L

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

80%

FVC < 80% Pred.

FVC NORMAL

millers prediction quadrants72
Millers Prediction Quadrants

100%

Air Entry is reduced

Restrictive Disease

FEV1÷FCV is High

Air In and Out N

Normal Lungs

FEV1÷FCV is N

FEV1 NORMAL

90%

90%

100%

60%

70%

80%

Both Air In & Out ↓↓

Combined Obs+Res

FEV1÷FCV is N or L

Air Exit is chocked

Obstructive Disease

FEV1÷FCV is Low

FEV1 < 80% of Pd.

70%

60%

FVC < 80% Pred.

FVC NORMAL

take home points
Take Home Points
  • All that wheezes is not Asthma only
  • All Dyspnoea does not wheeze
  • Do not over simplify dyspnoea to Deriphyllin
  • Etiology of Dyspnoea needs elucidation
  • Spirometry tests but Ventilation function only
  • Need to test diffusion, Perfusion functions
  • Cardiac, Hematologic and other causes