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Pulmonary Function Test

This document provides an overview and refresher on pulmonary function tests (PFTs). It describes the purpose and types of PFTs, including standard tests like spirometry, lung volumes, and gas transfer tests. It outlines the categories of obstructive, restrictive, and mixed lung disease patterns seen on PFTs. The document discusses validity criteria and provides examples of normal and abnormal PFT patterns. It also includes practical scenarios describing how to interpret PFTs and arrive at likely diagnoses.

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Mohammed Saad Nabhan
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101 views77 pages

Pulmonary Function Test

This document provides an overview and refresher on pulmonary function tests (PFTs). It describes the purpose and types of PFTs, including standard tests like spirometry, lung volumes, and gas transfer tests. It outlines the categories of obstructive, restrictive, and mixed lung disease patterns seen on PFTs. The document discusses validity criteria and provides examples of normal and abnormal PFT patterns. It also includes practical scenarios describing how to interpret PFTs and arrive at likely diagnoses.

Uploaded by

Mohammed Saad Nabhan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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PULMONARY

FUNCTION TESTS
– A REFRESHER
Khizer Hayat Khan
M Rahim Khan
York Teaching Hospital
INTRODUCTION

• Pulmonary function tests (PFTs) are non-invasive tests that show how
well the lungs are working.
• The tests measure lung volume, capacity, rates of flow, and gas
exchange
PURPOSE OF PFTs

• Diagnosis of symptomatic disease


• Screening of early asymptomatic disease
• Monitoring response to treatment
• Prognostication of known disease
TYPES OF PFTs

Spirometry
STANDARD PFTs Lung volumes
Gas transfer
Exercise oximetry
SPECIALIZED PFTs 6 minute walk test
Peak flow
CATEGORIES OF LUNG DISEASES

• PFTs help classify disease in following categories:

• OBSTRUCITVE | This is when air has trouble flowing out of the lungs
due to airway resistance. This causes a decreased flow of air

• RESTRICTIVE | This is when the lung tissue and/or chest muscles can’t
expand enough

• PULMONARY VASCULAR DISEASES |


SPIROMETRY
VALIDITY OF PFTs

• Evaluate acceptability & reproducibility


• Acceptability
• Good effort – a rapid increase in airflow at the start of exhalation
• Complete maneuver – at least 6s of exhalation ending up in plateau in flow

• Reproducibility
• All 3 FEV1 within 200ml of each other
• All 3 FVC within 200ml of each other
LUNG VOLUMES
LUNG VOLUMES
VOLUME AGAINST TIME
FLOW VOLUME LOOP
SPIROMETRY PATTERNS

• Normal
• Obstructive
• Restrictive
• Mixed
• Fixed upper airway obstruction
• Variable intra thoracic upper airway obstruction
• Variable extra thoracic upper airway obstruction
OBSTRUCTIVE SPIROMETRY
• FEV1:FVC ratio <70%
• FEV1 falls disproportionately greater than FVC
• Conditions such as Asthma, COPD, Bronchiectasis and CF
RESTRICTIVE SPIROMETRY

• FEV1:FVC ratio >80%


• Reduction of FEV1 and FVC
• Conditions such as ILD, pleural disease, NMD, Diaphragm dysfunction,
kyphoscoliosis, obesity and pregnancy
MIXED OBSTRUCTIVE/RESTRICTIVE

• FEV1:FVC ratio<70%
• Reduction in FVC
FIXED UPPER AIRWAY OBSTRUCTION

• Flow volume loop: flattening in both


inspiration and expiration
• Maximal flow rates limited
• Causes: tracheal/bronchial stenosis,
goitre, upper airway tumours
VARIABLE EXTRA THORACIC OBSTRUCTION

• Acceleration of air into the lung reduces


intraluminal pressures causing collapse at the
site of extra thoracic obstruction.
• Flattened inspiratory flow curve
• Normal expiratory flow curve
• Causes: vocal cord paralysis, airway burns,
glottic strictures
VARIABLE INTRATHORACIC OBSTRUCTION

• Decreased intrathoracic pressure splints


open the airway lumen at the site of
intrathoracic obstruction
• Normal inspiratory flow curve
• Flattened expiratory flow curve
• Causes: tracheomalacia, polychondritis,
low tracheal/bronchial tumours.
DIFFUSION CAPACITY OF CO

• (DLCO) is also known as the transfer factor for carbon monoxide or


TLCO
• It is a measure of the conductance of gas transfer from inspired gas to
the red blood cells.
DLCO

Conditions and physiologic states that alter DLCO

INCREASED DLCO
• Exercise
• Asthma
• Polycythaemia
• Pulmonary haemorrhage
DECREASED DLCO
• Emphysema
• ILD
• Anaemia
Low Normal/High
Assess FVC Assess FEV1/FVC Assess FVC

Normal/High
Assess TLC Normal lung
Assess TLC
mechanics

Variety of
Mixed Obstruction Restriction Assess DLC
explanations

Pulmonary
Assess DLCO Assess DLCO Normal PFTs
vascular disease

Chronic CWD/NMD/
Emphysema Probable ILD
Bronchitis/Asthma Obesity
PRACTICAL SCENARIOS
Pattern recognition

The major limitation of PFTs is how they are


interpreted

KEYPOINTS PFTs not standalone test

Requires organized approach

Identify and quantitate the abnormality


NORMAL
“Triangle over a semicircle”
FVC 4.68

FEV1 3.38

FEV/FVC = 3.38/4.68 = 0.72 or 72%


TLCO = KCO x VA
Don’t mix up TLC & TLCO!

TLC – Total Lung Capacity

TLCO – Transfer capacity of the Lung for Carbon monoOxide


(may also be referred to as DLCO – Diffusion Capacity of the Lung for Carbon
monOxide)
CASE 1
…53 year old gentleman with history
of asthma, complaining of dyspnea,
wheeze and cough. He had some relief
with inhaled therapy but remains
symptomatic. He is an ex-smoker of 22
pack year. I am concerned whether he
has developed COPD over the years
that he was smoking…
𝚫 350ml
𝚫 530ml

FEV1/FVC <70% OR <LLN? BRONCHODILATOR REVERSIBILITY

GOLD - <70% ≥200ml & ≥12% 𝚫 in either FEV1 or FVC


ATS - <LLN
Mild | FEV1 >=80%

SEVERITY OF AIRFLOW Moderate | 80%< FEV1 >=50%


OBSTRUCTION Severe | 50%< FEV1 >=30%

Very severe | FEV1 <30%

…..only if FEV1/FVC is obstructive


80-120% | Normal
<80% | Restriction 80-120% | Normal
>120% | Hyperinflation >120% | Air trapping
 Airwary inflammation
 Airway obstruction
 Moderate severity
 Positive bronchodilator response
 Hyperinflation
 Gas trapping
 Slightly increased gas transfer

ASTHMA
CASE 2
…48 year old lady with COPD.
Current smoker of 30 cigarettes
a day. Remains short of breath
despite optimum treatment for
her COPD…
𝚫 0.05ml
𝚫 0.07ml
 Severe airways obstruction
 No reversibility
 Hyperinflation
 Gas trapping
 Reduced transfer factor

EMPHYSEMA
CASE 3
...65 year old lady with
exertional shortness of breath
for 6 months. No other
respiratory symptoms. Hx of SLE
and recurrent UTIs. She is on
Prednisolone, Methotrexate and
Nitrofurantoin. She smoked 20
cigarettes a day for 31 years and
quit 18 years ago...
Restriction is graded by the decrement in FVC or TLC

SEVERITY OF % OF PREDICTED
RESTRICTION Mild 80-65%

Moderate 65-50%

Severe <50%
FVC

FVC

TLC

RV

RV
Restriction - Pulmonary or Extrapulmonary?

• Extrapulmonary causes of restriction


• Large pleural effusion/pleural thickening
• Neuromuscular disease
• Chest wall deformity
• Obesity
 Restrictive lung disease
 Moderate severity
 Reduced gas transfer

ILD
CASE 4
… 60 year old lady symptomatic
with progressive shortness of
breath on exertion for several
months. No other respiratory
symptoms of note. She never
smoked and has no past medical
history of note. Her only
medications is hormone
replacement therapy…
SPIROMETRY GAS TRANSFER DIAGNOSIS
Reduced Emphysema
Obstructive Normal Chronic bronchitis
Normal / Increased Asthma
Reduced Intrinsic lung disease
Restrictive
Normal Extrapulmonary restriction
Anaemia
Normal Reduced
Pulmonary vascular disease
Restrictive/Normal Increased Pulmonary haemorrhage
 Normal spirometry
 Normal lung volumes
 Reduced gas transfer

Pulmonary vascular disease


CASE 5
... 25 year old gentleman with
mild asthma well controlled
with PRN Salbutamol. Has been
symptomatic with dyspnea and
wheeze for a year. 2 years ago
he was involved in a road
traffic accident and was
intubated and ventilated. He
had a tracheostomy that was
removed 2 months after his
discharge from the hospital...
Don’t just look at the numerical values

EMPEY’S INDEX
FEV1 (ml) / PEF (L/min)
>10 suggests upper airway obstruction
The higher the ratio, the greater the obstruction
REFERENCES / USEFUL RESOURCES

• ERS Handbook of Respiratory Medicine 2nd edition


• Oxford Handbook of Respiratory Medicine, 3rd edition
• www.depts.washington.edu/uwmedres/Library/eLearning/Pulmonary
• Interpretting PFTs, Clevelenad Journal of Medicine
• Ruppel’s Mannual Of Pulmonary Function Testing, 11th edition
• UpToDate.com – Interpretting pulmonary function testing

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