99

SPIROMETRY IN PRACTICE
A Real Life Approach

Dr. Jyotsna Joshi, M.D.

Mumbai, India

This book is published by

Cipla Ltd.
In support of Comprehensive COPD Care
Medicine is an ever-changing science. As new research
and clinical experience broadens our knowledge, changes
in treatment and drug therapy are required. This book
is based on sources believed to be reliable in providing
information that is complete and generally in accordance
with the standards accepted at the time of publication. Any
change in medical science may necessitate suitable modifi
cations of the information contained herein.

Every effort has been made to ensure that the drug doses
and other information are presented accurately in this
publication. However, the ultimate responsibility rests
solely with the attending physician.

ii
INDEX

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

Chapter 1: General Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

Chapter 2: Simple Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3: Advanced Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Chapter 4: Case studies on Spirometry (14 examples) . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 5: Asses your knowledge on Spirometry with 40 test exercises . . . . . . . . . . . 42

Answers to test exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

iii
iv
Foreword
Spirometry is an integral part of the evaluation, diagnosis and
management of patients with respiratory disorders. Experts describe
it as akin to using and electrocardiogram for patients with heart
disease or even a sphygmomanometer for measuring blood pressure.
Yet, many doctors tend to rely only on a clinical examination and
chest X-ray for the assessment of patients with respiratory diseases.
With technological advancements, spirometry has become simple,
inexpensive and reliable and can be easily incorporated in physician’s
clinic.
The purpose of this publication is to familiarise physicians who want
to get started on spirometry and use it in their day-to-day practice.
It covers the basics of spirometry, describes methods for conducting
it and provides simple algorithms for interpretation of result. More
importantly, the book follows a case-study approach, which makes it
easy to understand the essence of spirometry and its applications in
day-to-day clinical situations.
“Spirometry In Practice: A Real Life Approach” is the outcome of
various workshops conducted across the country addressing the issues
faced by physicians. The overall objective is to make spirometry a
routine test in the general evaluation of all patients with obstructive
airway disease.

Dr. Jyotsna Joshi, M.D.

2016

1
Glossary

• ATS - American /Thoracic Society • Obstructive ventilator defect - Characterised by

airflow limitation, for example reduced FEV1, FEV1/
• BDR - Bronchodilator Reversibility
FVC ratio or PEF. The term ‘airflow limitation’ is
• ERS - European Respiratory Society also used and is, perhaps, a more accurate term
than ‘obstruction’ as reduced expired flows can
• FEF25-75% - Forced expiratory flow over the middle arise not only due to abnormal airway calibre,
half of the FVC manoeuvre. This is the average but also in altered parenchymal compliance and
expired flow over the middle half of the FVC impaired mechanical linkage between airways and
manoeuvre. Normally reported in L/s. lung parenchyma.
• FEF50% - Forced expiratory flow at 50% of the FVC. • PEF - Peak expiratory flow (L/s or L/min). This is
This is the maximal expiratory flow measurement the maximal expiratory flow achieved during a
at the point where 50% of the FVC has been expired. maximum forced expiration initiated at TLC. The
Normally reported in L/s. PEF occurs very early in the forced expiratory
• FEV1 - Forced expired volume in 1 second. This is manoeuvre.
the volume expired (in L or mL) in the first second • Pneumotachometer or pneumotachograph -
of maximal expiration (initiated after a maximal Device for measuring flow from the pressure drop
inspiration) across a uniform and known resistance under
conditions of laminar flow.
• FEV1/FVC ratio - The FEV1 expressed as a percentage
of the VC or FVC. The normal ratio. This is also • Restrictive ventilatory defect - Characterised by loss
referred to as the forced expiratory ration, FER%. of lung volume in the absence of airflow limitation.
As suggested by a low VC or FVC but normal or high
• FV loop - Flow-volume loop. A plot of maximal
FEV1/FVC ratio. If lung restriction is suspected on
expired and inspired volume versus flow. Most of
spirometry, format measurements of lung volumes
the expiratory curve is effort-independent and the
should be done to confirm and quantify it (for
entire inspiratory curve is effort-dependent.
example multi-breath inert gas dilution, nitrogen
• FVC - Forced vital capacity (L or mL). The maximum washout or whole body plethysmography).
volume of air that can be expired during a forced • Reversibility - Improvement in ventilator function
expiratory manoeuvre initiated from TLC. (for instance, FEV1) following the inhalation of a
• FIF50% - Forced inspiratory flow at 50% of the vital bronchodilator.
capacity during a maximal inspiratory manoeuvre • Spirogram - A plot of respired volume versus time.
• Hyperinflation or air trapping - This term refers • Spirometer - Instrument used to measure respired
to a significant increase in static lung volumes, i.e. volume. Spirometers may be classified as either
total lung capacity, or function residual capacity, or volume or flow spirometers depending on whether
residual volume. the primary signal measured is volume or flow.
• Mixed ventilator defect - Characterised by both • Spirometry - Physiological test to measure the
airflow limitation (obstruction) and loss of lung ventilator function of the lungs.
volume (Lung restriction). Produces both a low • TLC - Total lung capacity (L or mL). Total volume
FEV1/FVC ratio and low VC (or FVC). The restrictive contained within the lung at full inspiration
component should be confirmed and quantified by
formal measurement of lung volume (for example, • VC - Vital capacity (L or mL). The maximum volume
multi-breath inert gas dilution, nitrogen washout of air that can be expired or inspired during a slow
or whole body plethysmography). manoeuvre initiated at TLC or residual volume,
respectively.

2
Chapter 1

General Considerations

1.1 Introduction
John Hutchinson, a surgeon, recognised that the volume of air that can be exhaled from
fully inflated lungs is a powerful indicator of longevity. He invented the spirometer
to measure what he called the vital capacity i.e., the capacity to live. Much later, the
concept of timed vital capacity, which became known as the forced expiratory volume
in 1 second (FEV1) was added.
Since the pulmonary function testing has become an important aspect of evaluation
of any respiratory disease. Several tests are used to study various aspects of pulmonary
functions. Amongst these spirometry is the most basic and useful method available for
evaluating pulmonary functions.
Spirometry is a simple expression of a complex process, just like blood pressure (BP). It
measure airflow during inspiration and expiration. Recording of expiratory flow from
fully inflated lungs is usually adequate and is called the vital capacity manoeuvre. Thus,
the forced vital capacity (FVC) is the volume of air exhaled during the first second of the
vital capacity manoeuvre.

Table 1.1 Indications for Spirometry

 Evaluation of cases with respiratory symptoms

 Assessment of severity of respiratory disorders
 Assessment of response to therapy
 Pre-operative pulmonary evaluation
 Detection of pulmonary functional abnormality in predisposed individuals.
E.g. occupational exposures, neuromuscular, chest wall or upper airway
disorders.

3
1.2 Types of Spirometers
Spirometers are essentially of two types – the older volume-
displacement spirometers and the newer flow-sensing
spirometers.
Flow-sensing spirometers are the most widely used as they are
portable and easy to maintain. They are either pneumotach-
based or turbine based. Advances in microprocessor
technology have led to the development of devices that
calculate the various parameters and percentage of the
predicted values for the patient.
The smaller hand-held equipment (Fig. 1.1) displays the
results on a screen or can be connected to a printer directly
for a print-out.
In addition, the computerised spirometers (Fig. 1.2)
automatically assess the acceptability of the test, store the
results and provide a print-out of the result, including the
spirogram and flow-volume loop.

1.3 Selecting a Spirometer

Several spirometers are available commercially, selection depends on the cost and
individual requirement. The American Thoracic Society (ATS) recommends that the
equipment should be such that:
• It can be calibrated with a 3 litre syringe.
• It should record at least FVC and FEV1.
• It should record a flow volume curve or a flow volume loop or both (if possible).

1.4 Maintaining a Spirometer

Calibrating the Spirometer

Spirometer should be accurate (volume within ± 0.05 L or ± 3%, whichever is greater;
flow within ± 0.2 L/sec of ±5%, whichever is greater).
Calibration should be performed periodically with a 3 litre syringe, ensuring that the
volume recorded by the instrument is close to 3 litres over the whole range of flows

4
 i.e. from 2.91 – 3.11 litres. In smaller hand-held equipment, testing someone with
stable lung function on the spirometer once a week is a practical way of checking the
accuracy.

Disinfecting the Spirometer

Lung function equipment has not been directly implicated in the transmission of
infections, although there is indirect evidence of infection transmission during
pulmonary function testing. Organisms from the respiratory tract of test subjects have
been recovered from mouthpieces and the proximal surfaces of tubing through which
subjects breathe.
The equipment must be disinfected periodically or disposable filter should be used
to prevent contamination. Mouthpieces must be cleaned and disinfected between
patients, or disposable mouthpieces, should be used to prevent cross-infection, which
can occur due to direct contact with saliva.

1.5 The Pulmonary Function Laboratory

Spirometry can be performed at the bedside, physician’s consulting room or a laboratory
Ambient temperature, barometric pressure and time of day must be recorded.
Temperature is an important variable in most pulmonary function tests and it may be
measured with a simple thermometer. Some instruments are equipped to measure the
temperature directly.

1.6 The Pulmonary Function Technician

The most important component in successful pulmonary function testing is a well-
motivated and enthusiastic technician. He should also be well-trained and experienced.
The current American Thoracic Society (ATS)/ European Respiratory Society (ERS)
guidelines (2005) suggested that completion of secondary education and at least two
years of college education would be required to fulfil the complete range of tasks
undertaken by pulmonary function technician. It is also essential to have quality control
programme with feedback to technicians in obtaining adequate spirometry results.

5
1.7 Contraindications for Performing Spirometry
It is recommended that patients should not be tested within 1 month of a myocardial
infarction,
Patients with any of the conditions listed below are unlikely to achieve optimal or
reproducible results:
• Chest or abdominal pain of any cause
• Oral of facial pain exacerbated by a mouthpiece
• Stress incontinence
• Dementia or confused state

1.8 Performing Spirometry

According to the current ATS/ERS statement may be performed either in the sitting or
standing position. The sitting position is considered safe in order to prevent falling due
to syncope. However, in obese subject, the standing position may be preferred.

Table 1.2 Activities that should be avoided prior to spirometry

 Smoking with 1 hour of testing.

 Consuming alcohol within 4 hours of testing.
 Performing vigorous exercise within 30 mins. of testing.
 Wearing clothing that substantially restricts full chest and abdominal expansion.
 Eating a large meal within 2 hours of testing.

If the study is performed to diagnose an airway disorder, then the following

bronchodilators must be omitted for the period indicated:
• Short-acting bronchodilators – within the previous 6 hours.
• Long-acting bronchodilators – within the previous 12 hours.
• Slow release theophyllines – within the previous 24 hours.
However, if the spirometry is carried out to determine a response to an existing therapy,
then one may choose not to withhold the bronchodilators.

6
1.9 The Spirometric Manoeuvre
The technician instructs and demonstrates the procedure to the patient. The patient
then performs spirometry in the following steps:

Expiratory Manoeuvre
• Take a full, deep breath away from the spirometer.
• Hold the mouthpiece between the lips to create a good seal.
• Expire as fast and as hard as possible for as long as possible until no breath is left.

Expiratory and Inspiratory Manoeuvre

• Hold the mouthpiece between the lips to create a good seal.
• Breathe in and out for 2– 3 tidal breaths.
• Expire as fast and as hard as possible for as long as possible until no breath is left.
• Inspire rapidly to maximum capacity.
Spirometry should be recorded again 15– 30 minutes after administration of a short-
acting beta-agonist, e.g. 200– 400 mcg of salbutamol, to check for bronchodilator
reversibility.
The patient should be encouraged continuously to ensure the best effort.

1.10 Recording Spirometry

Spirometry is recorded graphically and numerically.
Graphically, it can be recorded as:
• Volume versus time (Spirogram).
• Flow rate versus volume.
– Flow Volume Curve when only expiratory flow is recorded, or
– Flow volume Loop when inspiratory flow is also recorded

7
 Normal
Obstructive abnormality
Restrictive abnormality

“Gradual upslope”

Volume (L)
in obstructive
abnormality

“Miniature, normal
shaped” graph
in restrictive abnormality

Time (Sec.)

a. Graphic display of volume versus time (Spirogram)

Normal
Obstructive abnormality
Restrictive abnormality
Flow rate (L/sec)

“Coving” of the
expiratory graph

“Normal shaped,
miniature” graph

Volume (L)

b. Graphic display of flow rate versus volume (Flow Volume Curve)

Flow rate (L/sec)

Volume (L)

c. Flow volume loop

8
1.11 Acceptable Tests
• The effort should be maximal, smooth and cough free.
• Exhalation time should be at least 6 seconds.
• End of test is indicated by a second volume plateau.
• Reproducibility as indicated by FVC should be within 5% or 100 ml between the
highest and next best test among 3 acceptable tests.
• If 3 reproducible tests are not available, up to 8 manoeuvres should be attempted.
• The best values of 3 acceptable tests ae used for interpretation.
• If after 8 manoeuvres, 3 reproducible tests are not available, then the test with highest
values may be used.

3 3
3

Volume (L)
Volume (L)

Volume (L)

2 2
2

1 1 Pre 1
Post

0 0 0
0 1 2 3 0 1 2 3 4 0 1
Time (Sec) Time (Sec) Time (Sec)
Incomplete expiration Delayed start Poor effort

4 6
8
6 4
4 2
(Sec)

(Sec)

(Sec)

2 2

0 0
1 2 3 4 5 1 2 0 1 2 3
-2
-4 -2 -2
Cough Incomplete Inspiration Poor effort

9
1.12 Choosing the Appropriate Test
The appropriate test depends on the clinical situation. For most cases Spirometry before
and after the administration of a bronchodilator is performed. For pre-operative
assessment for lung resection, simple spirometry with calculation of predicted post-
operative values is required. If upper airway obstruction is suspected, flow-volume
loop should be performed.

Reversibility Testing

Bronchodilator Reversibility
Spirometry recorded 15– 30 minutes after administration of a short-acting beta-agonist,
e.g. 200-400 mcg of salbutamol is used to assess bronchodilator reversibility.

Calculation of Bronchodilator Reversibility

Calculation of % Improvement
FEV1 (post-bronchodilator) – FEV1 (baseline) x 100
FEV1 (baseline)

Steroid Reversibility
However, in some cases of poorly treated persistent asthma bronchodilator reversibility
may not be present, when steroid reversibility can be demonstrated after a course of
oral prednisolone in a single daily dose of 1 mg/kg for 2 weeks.

Calculation of Steroid Reversibility

Calculation of % Improvement
FEV1 (post-steroid) – FEV1 (baseline) x 100
FEV1 (baseline)

10
Chapter 2

Simple Spirometry

Simple spirometry is the recording of expiratory flow where the basic parameters, FVC,
FEV1 and peak expiratory flow (PEF) before and after bronchodilators are available for
interpretation.

2.1 Simple Spirometric Parameters

Although advanced spirometers give a large number of parameters in the report
(Fig. 2.1), only the following are necessary for routine interpretation:
• FVC recorded in litres and as percentage of predicted FVC%.
• FEV1 and as percentage of predicted FEV1%.
• FEV1/ FVC%, which is the ration of the patient’s recorded FEV1 and FVC.
• PEF in litres per minute or litres per second and as percentage of predicted PEF. Daily
PEF recording using a peak flow meter is an excellent way of monitoring asthma
control.
• Post-bronchodilator change in FEV1 is noted and an improvement by 12% and 200
ml is considered as good bronchodilator reversibility (BDR).

11
 Figure 2.1: Typical Spirometric Report Print-Out

Pre Test Comments: PRE-BRONCH

Post Test Comments:
Pred. Actual %Pred.
SPIROMETRY
FVC (L) 2.96 0.47 16
FEV0.5 (L) 2.29 0.40 17
FEV1 (L) 2.72 0.45 16
FEV3 (L) 3.33 0.47 14
FEV1/FVC (%) 83 95 115
FEV3/FVC (%) 100
FEF25% (L/sec) 6.34 2.71 43
FEF50% (L/sec) 4.11 1.07 26
FEF75% (L/sec) 1.61 0.29 18
FEF25-75% (L/sec) 4.30 0.84 20
FEFMax (L/sec) 7.55 2.64 35
FIVC (L) 3.30 0.56 17
FIF50% (L/sec) 5.76 1.57 27
FIFMAX (L/sec) 4.33 1.57 36
FET25-75% (sec) 0

Maximal Mid-Expiratory Flow (MMFR) or Forced Expiratory Flow between 25-75%

(FEF25-75%) is the average expired flow over the middle half of the expiration
(FVC manoeuvre) and was regarded as a sensitive measure of small airways obstruction.
However, more recently, MMFR is not considered a reliable parameter, as it is poorly
reproducible. MMFR depends on the mid-portion of expiration, which may vary widely
depending on the duration of expiratory or FVC manoeuvre between tests.

2.2 Predicted Values

All the above parameters are read as normal or abnormal when compared to predicted
values.
Predicted values vary as per age, sex, height and ethnic groups, are obtained by large-
scale studies in the community and are readily available for use. Values above 80%

12
 of predicted are generally considered as normal. For patients with a deformity of the
thoracic cage, such as kyphoscoliosis, the arm span from fingertip to fingertip can be
used as an estimate of height. Caucasians have the largest FEV1 and FVC and, of the
various ethnic groups, Polynesians are among the lowest. There is little difference in
PEF between ethnic groups. The values for black Africans are 10-15% lower than for
Caucasians of similar age, sex and height because, for a given standing height, their
thorax is shorter. The Chinese have been found to have an FVC about 20% lower and
Indians about 10% lower than matched Caucasians. Approximate conversion factors
for adjusting European reference values of FVC and FEV1 for Indians are 0.9 for North
Indians and 0.87 for South Indians.
FEV1, FVC and PEF increase, while FEV1/ FVC% decreases, with age until about 20 years
of age in females and 25 years in males; after this, all indices gradually fall. The fall in
FEV1/ FVC% with age in adults is due to the greater decline in FEV1 than FVC.

2.3 Interpretation of Simple Spirometry

Although the terms ‘’functional abnormality’’ and ‘’disability’’ are used to mean the
same, spirometry can interpret functional abnormality whereas the effect of this
abnormality on the individual’s life is termed disability. The same degree of functional
abnormality can result in different levels of disability depending on the individual’s
lifestyle (active or sedentary).
Two basic types of pulmonary function abnormalities, restrictive and obstructive
abnormalities are described using the spirometric parameters:
• Restrictive abnormality FVC (obs)/FVC (pred) <80%
• Obstructive abnormality by FEV1/FVC <70%
• If obstructive abnormality is present, it is important to know if this is associated with
good BDR indicated by improvement in FEV by 200 mL and >12%. This criterion for
BDR is for spirometry interpretation only and should not be used to determine use of
bronchodilator therapy.

13
 Figure 2.2: Interpretation of Spirometry

Spirometry in Restrictive Abnormality

Simple spirometry parameter, i.e. reduced FVC% predicted, along with clinic-
radiological correlation help in diagnosing restrictive abnormality (Fig. 2.2). However,
when available, the spirogram and FV loop graphs are characteristic to appreciate
presence of restrictive abnormality. Spirogram and FV loop are typically ‘’normal
shaped, miniature’’ graphs (Fig. 1.3). FVC% predicted is used to determine the severity
of restriction.

14
• Mild: FVC% between 60-80%.
• Moderate: FVC% between 45-60%.
• Severe: FVC% less than 45%.
Restrictive abnormality occurs due to:
• Chest wall diseases, including skeletal and neuromuscular disorders
• Pleural diseases
• Parenchymal diseases
• Interstitial lung diseases (ILD)
A characteristic pattern of restrictive abnormality in ILDs is preservation of flow rates
resulting in the FV loop seen as a ‘’narrow but tall’ graph whereas in other types of
restrictive abnormalities, there is reduction of the flow rates along with reduction of
FVC, so that the FV loop is seen as a ‘’normal shaped, miniature graph’’.

Spirometry in Obstructive Abnormality

Simple spirometry parameters defined by reduced FEV1/FVC% (<70%) diagnose
obstructive abnormality (Fig. 2.2). Change in FEV form baseline is used to assess BDR.
Although, bronchial asthma usually shows good BDR and chronic obstructive pulmonary
disease (COPD) shows poor BDR, this is not always true.
FEV1% predicted is used to grade severity of the obstructive abnormality. However,
when available, the spirogram and FV loop graphs are characteristic to appreciate
presence of obstructive abnormality Spirogram typically shows a ‘’gradual upslope’’
(due to reduced FEV1 and FV loop shows ‘’coving of the expiratory flow’’ (Fig. 1.3).
Obstructive abnormality is seen in

Bronchial asthma

COPD

Bronchiectasis
Note: FVC can be reduced in moderate to severe airflow obstruction due to air trapping
(and often improves along with FEV1 post bronchodilator). Hence, to interpret a
restrictive abnormality in these case, clinical and radiological correlation is necessary.
If facilities are available, lung volume measurements, Residual Volume (RV) and Total
Lung Capacity (TLC) may be performed to confirm restrictive abnormality where both
RV and TLC will be reduced.

15
Spirometry in Asthma
Asthma is characterised by an obstructive abnormality with a good BDR. Assessment
of asthma severity (Global Initiative on Asthma-GINA guidelines) is necessary for the
recommended step care approach to management of asthma. Asthma severity based
on spirometry is classified as follows:

Severity FEV1%
Intermittent >80%
Mild persistent >80%
Moderate persistent 60-80%
Severe persistent <60%

In intermittent asthma, spirometry may not show any abnormality when performed
during the asymptomatic period. It should be repeated during the symptomatic periods
to show the obstructive abnormality and BDR.
Or
Airway hyper-reactivity may be demonstrated by doing a spirometry following 5 minutes
of exercise (e.g. running) to show a drop in FEV1 by 12-15%. Although methacholine or
histamine challenge can be performed, it is rarely required in clinical practice and must
be performed in a well-quipped laboratory.
In a very poorly treated persistent asthma, BDR may not be present, in which case a
steroid reversibility can be demonstrated after a short course of oral steroids.

Spirometry in COPD
COPD is characterised by an obstructive abnormality with poor BDR. However, some
cases, particularly those with predominant bronchitis may show good BDR.

Role of Spirometry in Estimating Severity of COPD

Spirometry is the gold standard for confirmation and assessing severity of COPD.
Spirometry shows decreased FEV1 with concomitant reduction in FEV1/FVC ratio with
a poor or absent BDR and normal or reduced FVC. FEV1/FVC% <70 is used to diagnose
COPD, whereas FEV1% is used to grade the severity. The assessment of severity of COPD
as per the Global Initiative On Obstructive Lung Disease (GOLD) guidelines based on
spirometry is done. (See Table 2.1).

16
Table 2.1: Classification of severity of COPD based on spirometry

0: At Risk Spirometry normal but symptoms evident

I: Mild FEV1/FVC% <70 FEV1 >80% predicted
II: Moderate FEV1/FVC% <70 FEV1 50-80% predicted
III: Severe FEV1/FVC% <70 FEV1 30-50% predicted
IV: Very Severe FEV1/FVC% <70 FEV1 <30% predicted

Spirometry to Monitor Development of COPD in Smokers

After the age of 25 years, the lung function of a normal individual begins to decline
at the rate of reduction in FEV1 by approximately 30 ml per year (Fig. 2.3). Patients
with COPD show an accelerated decline of lung function, almost up to 70 ml per year.
However, only 15% of smokers develop COPD, probably due to a genetic predisposition.
Thus, an annual monitoring of spirometry in smokers can help identify the subgroup of
smokers who are susceptible to the development of COPD. The Lung Health Study was
the first study to show that simple spirometry could detect mild airflow obstruction,
even in asymptomatic patients.
Figure 2.3: Role of Spirometry in monitoring development
of COPD in susceptible smokers
FEV1 DECLINE
100 Never smoked or not
susceptible to smoke
FEV1 (percentage of value at age 25)

75
Susceptible
50 smoker

Disability

50
Death

25 50 75
Age (years)

17
 Role of spirometry in estimating ‘’lung age’’ in COPD to aid smoking cessation
Spirometry is the gold standard for diagnosis of COPD. Spirometry can also be used
for assessing the ‘‘lung age’’ (measured FEV1) of a patient of COPD as compared to the
predicted FEV1 as per his chronological age. Demonstration of this graphic illustration,
e.g. 45-year-old man with COPD with a ‘‘lung age’’ of an 80-year-old (Fig. 2.4) is also
helpful in encouraging smokers to quit smoking.

5
Normal, non-susceptible

4
Lung volume (litres)

3 COPD

25 35 45 55 65 75 85

Age (years)

2.4 PEF Monitoring in Airway Obstruction

Serial peak flow measurements have become an integral part of asthma care. PEF
is a simple measure recorded using a hand-help peak flow meter. The recording of
PEF appears logical in COPD. However, there are important physiological differences
between COPD and asthma, which limit the value of PEF in COPD. In asthma, there is
a reasonably good correlation between PEF and FEV1, which allows the use of PEF as a
surrogate for FEV1. Because the amount of airway collapsibility varies between COPD
patients, the relationship between PEF and FEV1 will also vary. PEF can be misleading
and therefore, it should not be used as a diagnostic tool in COPD.

2.5 Limitations of Spirometric Parameters

Spirometry is only a diagnostic aid and should always be interpreted with clinical and
radiological correlation. The same degree of functional abnormality on spirometry may
result in different degrees of disability in different patients.

18
 FEV1/FVC
• There is a normal age-related decline in the FEV1/FVC% as explained earlier, so normal
elderly patients without airways obstruction will have a ratio below 70-80%.
• False normalisation of FEV1/FVC may occur in moderate to severe airway obstruction
caused by marked fall in FVC due to air trapping.

FVC
• FVC is dependent on the patient’s performance therefore, reduced FVC only suggests
a restrictive abnormality.
• Reduction in FVC may occur due to air trapping in moderate to severe airway
obstruction.

BDR
• Cases of obstructive abnormality with poor BDR, must be given a steroid challenge
when appropriate.

19
Chapter 3

Advanced Spirometry

The application of spirometry can be expanded by recording of flow volume loops,

recording of spirometry in various positions, using alternative routes like the nasal and
through tracheostomy.

3.1 The Role of Spirometry in All Types of Airway Obstruction

Although classically, the term obstructive abnormality implies obstruction of large
airways, e.g. asthma and COPD, it is important to know the functional division of the
airways and the role of spirometry in obstruction of the upper and small airways. Both
are often missed in clinical practice and spirometry can be extremely helpful in timely
diagnosis and appropriate management of these conditions.

Functional Classification of Airways

Functionally, the airways can be divided as (Fig. 3.1)
Upper airways: From the nose/mouth to cariniLarge Airways: From carini to 2 mm
diameter airwaysSmall airways: Less than 2 mm diameter airways

Figure 3.1: Functional Anatomy of the Airways

Upper airways

Carina

Large airways

Small airways < 2mm

20
 Types of Airways Obstruction

Upper Airway Obstruction (UAO) cannot be diagnosed on “simple spirometry” and
requires recording of flow volume loops. Diagnosis of UAO can be made easily by
inspecting the pattern of the FV loop (Fig. 3.2) and calculation of certain indices
with appropriate clinical and radiological correlation.
Examples of UAO are tracheal stenosis, tracheal compression by goitre/mediastinal
masses and neoplasms of the larynx/trachea. UAO is discussed in more detail later.

Large Airway Obstruction (LAO), the commonest cause for airway obstruction
is conclusively determined even by simple spirometry parameters defined by
reduced FEV1 /FVC%, as obstructive abnormality (discussed earlier). However, when
the available graphs, i.e. spirogram and FV loop are characteristic to appreciate
the presence of obstructive abnormality, a spirogram typically shows a “gradual
upslope” (due to reduced FEV1) and the FV loop shows “coving of the expiratory
flow” (Fig. 1.3).
Examples of conditions where LAO predominates are Brochial Asthma and COPD
(Predominant Bronchitis)

Small Airway Obstruction (SAO), on the other hand, is best diagnosed by high-
resolution computed tomography (HRCT) showing “mosaic perfusion”, while
spirometry is helpful only with clinical and radiological correlation. Typically,
spirometry in SAO shows low FVC (due to air trapping distal to the obstructed small
airways), low FEV1 and flow rates. A characteristic feature is a “paradoxical fall” in FEV1
/FVC% due to greater increase in FVC compared to FEV1 following bronchodilators.
An example of SAO is obliterative bronchiolitis (OB) also called constructive
bronchiolitis (CB). SAO is also seen associated with bronchial asthma, COPD and
bronchiectasis.

3.2 Flow Volume Loops in Upper Airway Obstruction (UAO)

FV loops must be recorded to diagnose upper airway obstruction (UAO). This can be
fixed, variable extrathoracic or variable intrathoracic. The term “fixed” implies that
UAO remains unchanged during inspiration and expiration, while “variable” implies
change of degree of UAO during inspiration or expiration.

21
UAO can be diagnosed by clinical and radiological correlation along with:
• Inspecting the pattern of the FV loop
• Calculation of indices
– Empey’s index: FEV1 in ml/PEF in L/min and
– FEF50/FIF50 (ratio of flow at 50% expiration and flow at 50% inspiration)

FV loop in UAO
Fixed UAO shows flattening of both expiratory and inspiratory portions of the FV loop,
“Box Pattern”.
Variable Extra Thoracic UAO causes flattening of the inspiratory portion of the FV loop.
Variable Intrathoracic UAO causes flattening of the expiratory portion of the FV loop.

Upper Airway Indices

The indices help confirm presence and identify the type of UAO.
Presence of UAO is indicated by:
FEV1 (ml)/PEF (L/m) >8 (Empey’s index)
Type is determined by:
FEF50/FIF50 = 1 in fixed UAO
FEF50/FIF50 >1 in variable extrathoracic UAO
FEF50/FIF50 <0.3 in variable intrathoracic UAO

22
 a. Variable Extrathoracic UAO

b. Variable intrathoracic UAO

c. Fixed UAO
Figure 3.2: Flow Volume Loop Interpretation in Upper Airway Obstruction

23
 Common causes of Upper Airway Obstruction (UAO)
Fixed UAO
• Benign stricture following prolonged endotracheal intubation
• Post tracheostomy tracheal stenosis
• Large goitre causing severe tracheal narrowing
Variable Extrathoracic UAO
• Goitre compressing the trachea
• Hypertrophied tonsils and adenoids
• Bilateral vocal cord palsyVocal cord dysfunction syndrome
• Pharyngeal or laryngeal growths
Variable Intrathoracic UAO
• Benign and malignant tracheal tumours
• Mediastinal masses compressing the thoracic trachea

Positional Change in UAO

FV loops should be recorded in those positions in which syndrome are maximal to
detect postural UAO. In some cases, e.g. large goitres, FV loop is normal when sitting. In
such cases, supine FV loops helps in detecting UAO.

3.3 Spirometry in Pre-Operative Pulmonary Evaluation

Pulmonary function testing is not routinely indicated for pre-operative evaluation.
However spirometry should be performed in patients requiring lung resection surgery
or in surgery other than lung resection (particularly thoracic or upper gastrointestinal
surgery) if there is history of tobacco smoking, or clinical or radiological findings suggest
pulmonary abnormality.

Pre-operative Evaluation in LUNG Resection Surgery

Predicted post-operative (ppo) values should be calculated by deducting the volume to
be resected from the pre-operative spirometric (usually FEV1) values. For this purpose
“rule of five” can be used which assumes one-fifth function for each lobe. For example,
if the recorded FEV1 is 2.5 litres and one lobe resection (lobectomy) is being considered,

24
 we will deduct one-fifth recorded FEV1 to calculate the ppo FEV1 in i.e. litres i.e. 2.5 L –
0.5 L = 2 L. Rarely, a perfusion scan may be performed to determine exact contribution
of the lobe/lung to be resected. Ppo FEV1 less than 40% predicted contraindicates any
lung resection.

Pre-operative Evaluation in Surgery Other Than Lung Resection

Pre-operative evaluation is done to assess the risk of post-operative pulmonary
complications and to minimise them by optimal treatment. Patients described as
high risk by spirometry can undergo surgery with an acceptable risk for post-operative
pulmonary complications. Risk is indirectly proportional to the distance of the surgical
site from the thorax.

3.4 Alternative Routes for Recording Spirometry

In Obstructive Sleep Apnoea (OSA), when conventional oral and sitting FV loops are
normal, as the nasopharynx is often the site of obstruction, nasal FV loops must be
recorded using the CPAP (Continuous Positive Airway Pressure) masks (Fig. 3.3).
Spirometry in patients with Tracheal Stomas is possible with the use of adapters, which
fit tightly onto the tracheostomy tubes (Fig. 3.4). The recordings are comparable to oral
recording and can be used to assess lung functions reliably.

25
Figure 3.3: Recording spirometry through tracheostomy

Figure 3.4: Recording spirometry through the nasal route

26
Chapter 4

Case studies on Spirometry (14 examples)

Spirometry Example 1

A 34-year-old healthy, non-smoker male was referred for medical evaluation prior to being
appointed as a clerk in a bank. He had no medical or surgical history. Chest X-Ray (CXR) and
electrocardiogram were normal.

Pre 10 Volume (L) Pre

4
Post 8 Post
3 6
Volume (L)

2 4
(L/sec)

2
1
0
1 2 3 4 5
0 -2
0 1 2 3 4 5 6 7 -4
Time (sec)
-6

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 4.0 L 3.2 3.2
FVC% (obs/pred) 80% 80%
FEV1 3.7 L 2.9 2.9 +0%-0 ml
FEV1% (obs-pred) 78% 78%
FEV1/FVC% 90% 90%
PEF 3.51 L/s 4.22 L/s

Interpretation: Normal Spirometry.

27
Spirometry Example 2

A 47-year-old male was referred for dry cough and progressive dysponea since 1 year.
On examination there was grade 3 clubbing and fine end inspiratory crackles on chest
auscultation. CXR showed bibasilar reticula opacities. HRCT showed changes of idiopathic
pulmonary fibrosis (IPF).
Diagnosis: Idiopthic Pulmonary Fibrosis.

3 Volume (L)

2
Volume (L)

1
(L/sec)

0
0 1 2 3 4 5 1 2 3 4

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 3.38 L 1.53 1.56
FVC% (obs/pred) 45% 46%
FEV1 2.94 L 1.5 1.55 +3%-50 ml
FEV1% (obs-pred) 51% 57%
FEV1/FVC% 98% 99%
PEF 4.2 L/s 3.51 L/s 4.22 L/s

Interpretation: Spirometry suggestive of restrictive abnormality (with clinical and radiological

correlation). Moderate restrictive abnormality as FVC is 45% predicted.

28
Remarks: Note that visual inspection of the FV loop suggests a restrictive abnormality.
However, spirometric values are required to confirm and assess severity of the restrictive
abnormality.
In restrictive abnormalities, the FEV1% is low in proportion to the low FVC, and unlike as in
obstructive abnormality, is not used as a parameter to indicate or assess airway obstruction.

Spirometry Example 3

A 24-year-old male, atopic, non-smoker had history of bronchial asthma since 4 years. On
examination, there were bilateral rhonchi present. CXR was clear.
Provisional Diagnosis: Bronchial Asthma.

8
Pre
5 Post 6
4
4
Volume (L)

3
(L/sec)

2
2
0
1
1 2 3 4 5
0 -2
0 1 2 3 4 5 6 7 8
Time (sec) -4

-6
Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 5L 4.2 4.5
FVC% (obs/pred) 84% 90%
FEV1 4.5 L 2.15 2.95 +37%-800
ml
FEV1% (obs-pred) 47% 65%
FEV1/FVC% 51% 65%
PEF 5.76 L/s 4.80 L/s 5.20 L/s

29
Interpretation: Obstructive abnormality with good BDR. Asthma severity, as per GINA
guidelines is severe persistent asthma (pre-bronchodilator FEV1 47% predicted).
Remarks: Note that visual inspection of the FV loop suggests an obstructive abnormality.
However, spirometric values are required to confirm, assess severity of the obstructive
abnormality and estimate the BDR.

Spirometry Example 4

35-year-old female, atopic, presented with symptoms of bronchial asthma since 5 years and
increased since 1 month. On examination, she was using her accessory muscles of respiration
and had diminished breath sounds. CXR was clear.
Diagnosis: Severe Persistent Bronchial Asthma.

3 8
Pre Volume (L) Pre
Post Post
6
2
4
Volume (L)

(L/sec)

2
1
0
1 2 3 4
0 -2
0 1 2 3 4 5 6 7 8 9 10
Time (sec) -4

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 3.2 L 1.54 2.3
FVC% (obs/pred) 48% 71%
FEV1 2.75 L 0.95 1.94 +104%-990 ml
FEV1% (obs-pred) 34.5% 72%
FEV1/FVC% 61% 84%
PEF 4.50 L/s 3 L/s 3.70 L/s

30
Interpretation: Severe obstructive abnormality with good BDR.
Remarks: Low vital capacity in the baseline spirometry was due to severe asthma related to
air trapping (as clinically and radiologically, there is no cause for restriction). Further, this is
confirmed by FVC% increasing to normal (83%) in the post-bronchodilator test. In case of a low
FVC due to a restrictive abnormality, no improvement is expected following bronchodilator
administration. Note that visual inspection of the FV loop suggests an obstructive abnormality.

Spirometry Example 5

Spirometry of the same case as in example 4 performed 3 months after treatment with
inhaled corticosteroids (ICS) and long-acting beta agonist (LABA) in fixed dose combination,
salmeterol and fluticasone (SFC).

8 Volume (L)
Pre Pre
4 6
FVC Post Post
3 4
Volume (L)

2
(L/sec)

1 0
1 2 3 4
0 -2
0 1 2 3 4 5 6
Time (sec)
-4

31
Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 3.2 L 2.55 2.75
FVC% (obs/pred) 79% 86%
FEV1 2.75 L 1.95 2.3 +18%-350 ml
FEV1% (obs-pred) 70% 84%
FEV1/FVC% 76% 83%
PEF 4.50 L/s 4.00 L/s 4.40 L/s

Interpretation: Obstructive abnormality with good BDR. Significant improvements in

spirometry after therapy; increase in FEV1 by 1 litre.
Remarks: Therapy with ICS and adequate bronchodilators results in remarkable improvement
in lung functions. Comparison with previous spirometric report is very important to assess
response to therapy in follow-up tests. The physician should make a note of the improvement
in the report in terms of absolute increase in FEV1 (and not in percentages) for future
comparisons. Note that visual inspection of the FV loop also shows the improvement.

Spirometry Example 6

A 55-year-old male, atopic, asthmatic since 7 years, presented with uncontrolled asthma
limiting his day-to-day activity and causing frequent nocturnal symptoms. His treatment
consisted of oral bronchodilators and occasional use of oral steroids. Recently, he had
been prescribed salbutamol by inhaler. He was using the inhaler sparingly for the fear of
“addiction”. On examination, he had bilateral rhonchi. Laboratory investigations were normal
and CXR was clear.

32
Diagnosis: Severe Persistent Bronchial Asthma.

Pre Pre
3 Post 4 Post

2 2
Volume (L)

(L/sec)
1 0
1 2

0
0 1 2 3 4 5 -2

Time (sec)
-4

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 2.75 L 1.1 1.5
FVC% (obs/pred) 40% 54%
FEV1 2L 0.9 1.0 +11%-100 ml
FEV1% (obs-pred) 31% 46%
FEV1/FVC% 81% 66%
PEF 3.70 L/s 1.00 L/s 3.20 L/s

Interpretation: With clinical correlation, spirometry is suggestive of obstructive abnormality

with poor BDR.
Remarks: Without clinical correlation and before analysing the post bronchodilator test, the
interpretation using the algorithm could result in and incorrect interpretation as “restrictive
abnormality.” Baseline spirometric values illustrate false normalisation of FEV1/FVC% due to
“air trapping” as a result of severe airway obstruction. This is evident by a fall in FEV1/FVC%
in the post-bronchodilator test. Although the absolute values of both have increased, the
increase in FVC is larger as compared to FEV1.

33
Spirometry Example 7

A 60-year-old male, non-atopic, 30 pack-year smoker, presented with cough, sputum and
dysponea with wheeze since 6 years. On examination, he had bilateral rhonchi. Laboratory
investigations were normal and CXR showed changes of emphysema.
Diagnosis: COPD.
3
Pre 8 Pre
Volume (L)
Post Post
6
2
4
Volume (L)

(L/sec)
2
1

0
1 2 3 4
0 -2
0 1 2 3 4 5 6 7 8 9 10
Time (sec) -4

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 2.3 L 1.8 1.8
FVC% (obs/pred) 78% 78%
FEV1 1.95 L 0.75 0.75 +0-0 ml
FEV1% (obs-pred) 38% 38%
FEV1/FVC% 41% 41%
PEF 3.10 L/s 1.30 L/s 1.34 L/s

Interpretation: Spirometry suggestive of obstructive abnormality without BDR is consistent

with the diagnosis of COPD. As the FEV1% predicted is 38%, COPD severity is GOLD class 3
(severe).
Remarks: The criterion of BDR is for spirometry interpretation only and should not prevent
use of bronchodilator therapy.

34
Spirometry Example 8

A 40-year-old male, non-atopic, non-smoker, presented with symptoms of chronic airway

obstruction and right heart failure. He had a history of pneumonia after which measles at the
age of 3 years, following which he complained of frequent “respiratory tract infection”. On
respiratory system examination, he had fine crackles and rhonchi. CXR was normal 2-D ECHO
showed pulmonary artery pressure of 60 mn Hg and dilated right artrium and right ventricle,
i.e. feature of cor pulmonale. HRCT thorax showed “mosaic perfusion” with few areas of
bronchiectasis (see visual) suggestive of Obliterative/Constrictive Bronchiolitis (OB)/CB.
Diagnosis: Post infectious OB/CB.

Spirometry Report

Test Predicted Bronchodilator Change

Before After
FVC 3.4 L 1.6 1.8
FVC% (obs/pred) 47% 53%
FEV1 2.8L 1.5 1.53 +2%-30 ml
FEV1 % (obs/pred) 53% 64%
FEV1/FVC% 93% 85%
PEF 4.5L/s 1.8L/s 2.0L/s

Interpretation: Finding of low FVC, low FEV1, normal FEV1/FVC%, with paradoxical fall in FEV1/
FVC% with clinic-radiological correlation are suggestive of small airway obstruction consistent
with the diagnosis of OB/CB.
Remarks: Without clinic-radiological correlation, the spirometry report suggests a restrictive
abnormality. In this case, the diagnostic algorithm will result in incorrect interpretation.

35
Spirometry Example 9

A 28-year-old male, non-smoker, atopic (History of eczema in grandmother) complained

of dyspnoea associated with wheezing approximately once in 2 months since last 2 years.
However, he did not have daily symptoms and he had no nocturnal symptoms. Respiratory
system examination was normal. CXR was normal.
Diagnosis: Intermittent Bronchial Asthma.
Spirometry when patient had no symptoms:

Test Predicted Bronchodilator Change

Before After
FVC 3.14 L 2.96 2.94
FVC% (obs/pred) 94% 94%
FEV1 2.43 L 2.4 2.4 0%-0 ml
FEV1 % 98% 98%
FEV1/FVC% 81% 81%
PEF 7.07 L/s 6.01 6.60
Spirometry during symptoms:

Test Predicted Bronchodilator Change

Before After
FVC 3.14 L 2.96 2.94
FVC% (obs/pred) 94% 94%
FEV1 2.43 L 1.73 1.94 12%-210 ml
FEV1 % 71% 77%
FEV1/FVC% 58% 63%
PEF 7.07 L/s 6.01 6.62
Interpretation: Spirometry when the patient has no symptoms is normal and FEV1 is >80%
to classify asthma as intermittent asthma. Spirometry during the symptomatic period shows
obstructive abnormality with good BDR.
Remarks: Spirometry should be performed during the symptomatic period in intermittent
asthma. However, spirometry should not be done during an acute episode of asthma
exacerbation.

36
Spirometry Example 10

A 65-year-old female, chronic smoker,

presented with cough and haemoptysis
since 1 year. On examination, she had
clubbing and signs of right upper lobe
collapse. CXR showed right upper collapse
with ‘’bronchus cut off’’ sign. CT thorax
confirmed that the right upper lobe
collapse was due to a growth obstructing
the right upper lobe. There were no
mediastinal lymph nodes. Bronchoscopy
revealed a mass in the right upper lobe
bronchus, which on biopsy showed features
of squamous cell carcinoma. She was referred for pre-operative pulmonary evaluation for a
right upper lobectomy.
Provisional Diagnosis: Right upper lobe collapse due to squamous cell carcinoma, stage T2,
NO, MO for pre-operative evaluation for right upper lobectomy.

Test Predicted Bronchodilator Predicted Pro

Before After
FVC 2.5 L 2.2 L 2.2 l 1.76
FVC% (obs/pred) 80% 80%
FEV1 2.0 L 1.75 1.75 1.4
FEV1% (obs/pred) 87.5% 87.5% 70%
FEV1/FVC% 79% 79%
PEF 3.4 L/s 3.28 L/s 3.34 L/s
Interpretation: Predicted post-operative (ppo) FEV1 greater than 1 L, hence the patient is fit
for right upper lobectomy.
Remarks: One lobe is to be resected, i.e. one-fifth of FEV1 (1/5 of 1.75 = .35 L) should be
deducted from the FEV1 to get the ppo FEV1, 1.75 L - .35 = 1.4 L.
ppo FEV1 (1.4L)/predicted FEV1 (2L) = 70%, hence ppo FEV1 = 70%.

37
Spirometry Example 11

A 27-year-old male, presented with stridor. He had been on prolonged tracheostomy for 2
months for mechanical ventilation following a vehicular accident. Clinical examination was
unremarkable, except for stridor on auscultation. CXR was clear. CT Thorax showed a 3 cm
narrowing of the trachea.
Diagnosis: Post tracheostomy tracheal stenosis.
The FV loop was as shown below:

2
(L/sec)

0
1 2 3 4
-2

-4

Interpretation: FV loop showing variable fixed UAO (‘’Box like FV loop’’) due to tracheal
stenosis.
Remarks: The interpretation is fairly easy even on visual inspection of the loop. However,
calculation of the upper airway indices further confirms presence of UAO and the type, i.e.
fixed UAO.

38
Spirometry Example 12

A 62- year-old female, presented with dyspnoea and stridor. On examination there were no
positive findings except stridor. CXR showed superior mediastinal widening. CT thorax showed
a large aortic aneurysm compressing and narrowing the intra-thoracic portion of trachea.
Diagnosis: Aneurysm of aorta causing variable intra-thoracic UAO.
The FV loop was as shown below:

Empey’s index = 10
FEF50/FIF50 = 0.28

Interpretation: FVL showing variable intra-thoracic UAD (flattering of the expiratory portion
of the FVL) as a result of compression of the intra-thoracic portion of trachea due to aortic
aneurysm.
Remarks: The interpretation is again fairly easy on visual inspection of the loop. However,
calculation of the upper airway indices further confirms the presence of UAO and the type,
i.e. variable intrathoracic UAO.

39
Spirometry Example 13

A 50 year-old male, presented with cough, dyspnoea and haemoptysis since 9 months. Clinical
examination showed a hard, supraclavicular lymph node. Respiratory examination showed
signs of left lung obstructive collapse. CXR (Visual) showed left lung collapse with “bronchus
cut off” sign.
Diagnosis: Left lung collapse due to bronchogenic carcinoma.
The CXR and FV loop were shown below:

POST
PRE
PRED

FEV1
FEV3
0 1 2
2

1
FEV1
0 1 2 3 4
Flow (L/sec) vs volume (L) vs
volume (L) Time (sec)

Interpretation: FV loop showed “bi-phastic” graph (arrow) due to unilateral main stem
bronchus obstruction.

40
Spirometry Example 14

A 40-year-old male, was referred with large euthyroid goitre and complain of dyspnoea in
supine position only. CXR was normal. X-ray neck and USG showed a large goitre.

Sitting Supine
Pre Pre
Post 6
4
4
2
(Volume L/sec)

(Volume L/sec)
2
0
1 2 3
0
-2 1 2 3

-2
-4

Empey’s index = 7 Empey’s index = 8.5

FEF50/FIF50 = 0.98 FEF50/FIF50 = 1.34

Interpretation: FV loop showing variable extrathoracic UAD due to goitre (flattering of the
inspiratory portion of the FV loop) in the supine position.
Remarks: The interpretation is fairly easy even on visual inspection of the two loops. However,
calculation of the upper airway indices further confirms presence of UAO in the supine FV
loop and the type, i.e. variable extra thoracic UAO.

41
Chapter 5

Assess your knowledge on Spirometry with 40 test exercises

The use of spirometry in evaluating and managing patients with lung disorders is as important (if
not more) as using an ECG for patients with heart disease. In continuation, further typical cases
that you would come across when you perform spirometry in your clinic are illustrated. Performing
spirometry routinely in patients with chronic respiratory symptoms will help you to diagnose
airway obstruction and serve as a valuable objective tool to convince your patients to follow your
treatment. This chapter helps in understanding step wise interpretation and application of your
knowledge of spirometry.

5.1 Interpretation of Spirometric Data

Interpretation of Spirometric Data
Note the following case illustrations, the accompanying spirometric graphs and reports.
Choose one or more correct answers from the options provided.
A typical computerised spirometry report (see below) has many parameters, all of which are
not required for routine interpretation of spirometry.

42
 Pre Test Comments: PRE-BRONCH POST-BRONCH
Post Test Comments:
Pred. Actual %Pred. Actual %Pred. %Change
SPIROMETRY
FVC (L) 3.17 1.03 32 1.32 42 28
FEV 0.5 (L) 2.32 0.32 14 0.38 16 16
FEV1 (L) 2.45 0.45 18 0.54 22 21
FEV3 (L) 3.26 0.72 22 0.91 28 27
FEV1/ FVC (96) 79 43 55 41 52 -6
FEF 25% (L/sec) 6.35 0.35 6 0.51 8 47
FEF 50% (L/sec) 3.62 0.18 5 0.28 8 55
FEF 75% (L/sec) 1.07 0.08 7 0.18 16 125
FEF 25-75% (L/sec) 2.83 0.15 5 0.27 10 75
FEF Max (L/sec) 7.09 1.44 20 2.26 32 57
FIVC (L) 3.45 1.19 34 1.73 50 56
FIF 50% (L/sec) 4.46 1.82 41 2.77 62 52
FIF Max (L/sec) 3.38 1.82 54 2.90 86 59
FET 25-75% (sec) 3 2 -43

As too many parameters make interpretation difficult; tabulate the important parameters as
below to make interpretation easy.

Test Predicted Bronchodilator %Change

Before After
FVC 3.17 l 1.03 (32%) 1.32 (42%)
FEV1 2.78 l 0.45 (55%) 0.54 (66%) (+21%, 90 ml)
FEV1/FVC% 43% 41%
PEF 7.59 L/s 4.03 L/s 4.43 L/s

Then, use the flow chart given below to interpret the report.

43
In case of asthma and chronic obstructive pulmonary disease (COPD), grade their severity
as follows:

Asthma Severity (Global Initiative on Asthma-GINA guidelines) (Rule: 60-80)

Severity FEV1% predicted
Intermittent ≥80%
Mild persistent ≥80%
Moderate persistent 60-80%
Severe persistent ≤60%

COPD severity (Global Initiative On Obstructive Lung Diseases-GOLD guidelines)

(Rule: 30-50-80)
Severity FEV1% predicted
Mild >80%
Moderate 50-80%
Severe 30-50%
Very severe <30%
For more help refer to “Spirometry In Practice: A Real Life Approach”

44
5.2 Assess your knowledge on Spirometry with 40 test exercises
For solutions see section on Answers to Test Exercises.

Spirometry Exercise 1a

45-year-old male. No clinical information available.

Test Predicted Bronchodilator

Before
FVC 2.8 L 0.6
FVC% (obs/pred) 22%
FEV1 2.75 0.5
FEV1% (obs/pred) 18.18%
FEV1/FVC% 84%
PEF 5.3 L/S 1.6
Interpret the spirometry.

Spirometry Exercise 1b

A 45-year-old male atopic, asthmatic since 7 years and on some herbal medications.

Test Predicted Bronchodilator Change

Before After
FVC 2.8 L 0.6 1.6L
FVC% (obs/pred) 22% 57%
FEV1 2.75 L 0.5 1.0L +100% - 500 ml
FEV1% (obs/pred) 18.18% 36.3%
FEV1/FVC% 84% 63%
PEF 5.3 L/S 1.6 4.8
Interpret the spirometry again. Note the incorrect interpretation of spirometry in
the absence of clinical information and post bronchodilator test.

45
Spirometry Exercise 2

21-year-old male with symptoms suggestive of asthma since 3 years. CXR clear.

Test Predicted Bronchodilator Change

Before After
FVC 3.37 L 2.86 3.11
FVC% (obs/pred) 85% 92%
FEV1 2.94L 2.06 2.66 29% - 600 ml
FEV1% 70% 90%
FEV1/FVC% 72% 85.5%
PEF 6.72L/s 4.97 6.71
Interpret the spirometry. Grade the severity of asthma.

Spirometry Exercise 3

70-year-old male, chronic smoker with a smoking index of 22 pack years, presented with
symptoms with symptoms suggestive of COPD since 6 years. Examination of respiratory
system showed signs of emphysema. CXR showed emphysematous changes.

Test Predicted Bronchodilator Change

Before After
FVC 3.22 L 1.69 1.82
FVC% (obs/pred) 52% 56%
FEV1 2.50 L 1.15 1.19 +3%
FEV1% 46% 48%
FEV1/FVC% 68% 66%
PEF 7.17L/s 4.48 4.41
Interpret the spirometry. Grade the severity of COPD.

46
Spirometry Exercise 4

An 18-year-old male presented with symptoms suggestive of bronchial asthma for one year.
His CXR was clear. He was being treated with salbutamol tablets as required. Recently, he had
a worsening of symptoms with frequent nocturnal awakenings and absenteeism from college.

Test Predicted Bronchodilator Change

Before After
FVC 3.2 L 1.54 2.3
FVC% (obs/pred) 48% 71%
FEV1 2.75 L 0.95 1.94 +104%-990 ml
FEV1% 34.5% 72%
FEV1/FVC% 61% 54%
PEF 4.5 L/s 3.00 L/s 3.70 L/s
Interpret the spirometry. Grade the severity of asthma.

Spirometry Exercise 5

23-year-old female, a case of diffuse scleroderma, complained of dry cough and progressive
increase in dyspnoea on exertion since 1 year. On respiratory system examination, there were
fine bi-basilar end inspiratory crackles. Chest rediograph and HRCT thorax was suggestive of
interstitial lung disease.
Diagnosis: Interstitial lung disease due to progressive systemic sclerosis

Test Predicted Bronchodilator Change

Before After
FVC 2.60 L 1.60 1.63
FVC% (obs/pred) 62% 63%
FEV1 2.17 L 1.32 1.34 1.5%-20 ml
FEV1% 61% 62%
FEV1/FVC% 83% 82%
PEF 5.85 L/s 5.34 4.56
Interpret the spirometry.

47
Spirometry Exercise 6

55-year-old male, non-addict, was referred for pre-operative assessment for night hernia
surgery. Patient had no respiratory complaints. There was no significant pulmonary or cardiac
illness in the past. His CXR and ECG were normal.

Test Predicted Bronchodilator Change

Before After
FVC 3.64 L 3.74 3.64
FVC% (obs/pred) 103% 100%
FEV1 3.17 L 3.23 3.24
FEV1% 102% 102%
FEV1/FVC% 86% 89%
PEF 7.05 L/s 5.98 6.00
Interpret the spirometry. Was a spirometry indicated in this case?

Spirometry Exercise 7

A 57-year-old chronic smoker presented with cough and haemoptysis since 6 months. On
examination, he had signs of grade 3 clubbing and signs of left lower lobe obstructive collapse.
CXR and CT thorax showed left lower lobe collapse with narrowing of the left lower lobe bronchus
due to an endobronchial mass. Histology of the mass showed squamous cell carcinoma. There
was no evidence of hilar/mediastinal lymphadenopathy or distant metastasis. A left lower
lobectomy was planned and he was referred for pre-operative pulmonary evaluation.
Provisional Diagnosis: Pre-operative evaluation for left lower lobectomy.

Test Predicted Bronchodilator Change

Before After
FVC 4.0 L 3.2 L 3.2 L
FVC% (obs/pred) 80% 80%
FEV1 3.4 L 2.5 2.5 2L
FEV1% (obs/pred) 74% 74% 59%
FEV1/FVC% 78% 78%
PEF 5.6 L/s 4.9 L/s 5.1 L/s
Interpret the spirometry. Is the patient fit for the planned left lower lobectomy?

48
 Spirometry Exercise 8 Spirometry Exercise 9

10 Volume (L)

8
2
6
(Volume L/sec)

4
0

(sec)
2 1 2 3 4

0 -2

-2 1 2 3 4 5

-4 -4

-6

Spirometry Exercise 10

POST
PRE
PRED
FEV1

0 1 2

FEV1

0 1 2

Flow (L/sec) vs Volume (L) Volume (L) vs Time (sec)

49
Spirometry Exercise 11

Kanuji, a 54-year-old male, atopic, non-smoker gave history suggestive of hypertension on

β blockers since 4 months. He had developed symptoms of bronchial asthma since 3 months.
On examination, there was wheeze present. Chest x-ray was clear.

Provisional Diagnosis: Hypertension with bronchial asthma.

Test Predicted Bronchodilator %Change

Before After
FVC 3.41 L 2.41 2.84
FVC% (obs/pred) 71% 83%
FEV1 2.78 L 1.53 1.84 (+20%, 310 ml)
FEV1/FVC% 63% 65%
FEV1% (obs/pred) 55% 66%
PEF 7.59 L/s 4.03 L/s 4.34 L/s

a) Obstructive abnormality with good bronchodilator reversibility. 

b) Obstructive abnormality with poor bronchodilator reversibility. 
c) Spirometry should be repeated after discontinuation of β blockers. 

50
Spirometry Exercise 12

A 52-yearold male, 19-pack year smoker gave history of cough and progressive dyspnoea
since 7 years. On examination there was wheeze present. Chest x-ray showed changes of
emphysema.

Provisional Diagnosis: COPD.

Test Predicted Bronchodilator %Change

Before After
FVC 3.53 L 2.7 2.79
FVC% (obs/pred) 77% 79%
FEV1 2.76 L 1.62 1.68 (+4%, 6 ml)
FEV1/FVC% 60% 60%
FEV1% (obs/pred) 59% 62%
PEF 7.5 L/s 5.05 L/s 5.58 L/s

a) Spirometry report shows obstructive abnormality. 

b) Spirometry shows restrictive abnormality. 
c) Spirometry report shows combined obstructive and restrictive abnormality. 

51
Spirometry Exercise 13

A 27-year-old female was referred for diffuse scleroderma. She complained of dry cough and
progressive dyspnoea since 1 year. On examination there were bibasilar fine end inspiratory
crackles. Chest x-ray showed bibasilar reticular opacities.

Provisional Diagnosis: Diffuse scleroderma with associated interstitial pulmonary fibrosis.

Test Predicted Bronchodilator %Change

Before After
FVC 3.38 L 2 2
FVC% (obs/pred) 59% 59%
FEV1 2.94 L 1.7 1.7 Nil
FEV1/FVC% 85% 85%
FEV1% (obs/pred) 58% 58%
PEF 5.4 L/s 3.51 L/s 4.22 L/s

a) Spirometry report shows obstructive abnormality. 

b) Spirometry shows restrictive abnormality. 
c) Spirometry report shows combined obstructive and restrictive abnormality. 

Spirometry Exercise 14

Lalit, a 23-year-old male, atopic, gave a history suggestive of bronchial asthma since 6 years.
He had never been evaluated or treated for asthma. He was taking cough syrups containing
salbutamol off and on for relief of symptoms. Of late, his symptoms had worsened with

52
severe breathlessness affecting his daily activities and frequent nocturnal symptoms. On
examination, there was wheeze. Chest x-ray was clear.

Provisional Diagnosis: Severe persistent bronchial asthma. Initial spirometry did not show
any bronchodilator reversibility. He was treated with oral corticosteroids for 2 weeks and
repeat spirometry as shown below.

Test Predicted Before and After %Change

2 Weeks of Oral Steroids
FVC 5.09 L 3.72 3.9
FVC% (obs/pred) 73% 78%
FEV1 4.31L 2.60 3.15 (+20%, 550 ml)
FEV1/FVC% 69% 81%
FEV1% (obs/pred) 59% 73%
PEF 4.76 L/s 2.8 L/s 3.2 L/s

a) Report shows obstructive abnormality with good steroid reversibility. 

b) Baseline study shows additional restrictive abnormality. 
c) Spirometry determined asthma severity is severe asthma. 

Spirometry Exercise 15

Amar Devi, a 58-year-old female non-atopic, non-smoker was seen with symptoms suggestive
of chronic airflow limitation since childhood after an episode of pneumonia associated with
measles. Chest x-ray was clear.

Test Predicted Bronchodilator %Change

FVC 1.81 L 0.56 1.2
FVC% (obs/pred) 31% 67%
FEV1 1.48 L 0.45 0.71 (+57%, 260 ml)
FEV1/FVC% 80% 60%
FEV1% (obs/pred) 30% 48%
PEF 4.17 L/s 1.89 L/s 2.36 L/s

53
a) Spirometry report shows restrictive abnormality. 
b) Spirometry report shows obstructive abnormality. 
c) Baseline study shows false normalisation of FEV1/FVC%. 

Spirometry Exercise 16

Savitri, a 37-year-old female presented with cough and haemoptysis since 6 months. On
examination, she had signs of grade 3 clubbing and signs of left lower lobe obstructive
collapse. Chest x-ray showed lower lobe collapse. She was referred for pre-operative pulmonary
evaluation for a Lobectomy.

Provisional Diagnosis: Pre-operative evaluation for Lobectomy.

Test Predicted Bronchodilator Predicted (ppo)

Before After
FVC 4.0 L 3L 3L
FVC% (obs/pred) 75% 75%
FEV1 3.0 L 2.5 2.5 ?
FEV1/FVC% 83% 83%
FEV1% (obs/pred) 30% 48%
PEF 6.0 L/s 5 L/s 5.2 L/s

a) Spirometry calculated ppo FEV1 is 2.3 L. 

b) Spirometry calculated ppo FEV1 is 2 L. 
c) Spirometry calculated ppo FEV1 is 2.25 L. 

Spirometry Exercise 17

Mahmood, a 54-year-old male, atopic (history of asthma in several family members) also a
20-pack year smoker presented with symptoms of chronic airflow limitation. Chest x-ray was
normal. Spirometry showed obstructive abnormality with good bronchodilator reversibility.

Provisional diagnosis: Asthma or COPD.

His previous spirometry report done in 2000 was reviewed and compared with that done in
2006.

54
 Test Observed Decline Over 6 Years
2000 2006
FVC 2.87 2.72
FVC% (obs/pred) 81% 84%
FEV1 2.16 1.90 260 ml
FEV1/FVC% 75% 70%
PEF 7.79% L/s 6.64 L/s

What is the annual decline in FEV1?

a) 43 ml per year. 
b) 70 ml per year. 
c) 30 ml per year. 

Spirometry Exercise 18

Sudha, an 18-year-old female presented with stridor. There was history of subtotal
thyroidectomy 2 months ago. Indirect Laryngoscopy showed bilateral vocal cord paralysis.

Provisional diagnosis: Upper airway obstruction due to bilateral recurrent laryngeal nerve
paralysis following thyroidectomy.

55
a) Spirometry report shows variable intrathoracic UAO. 
b) Spirometry report shows variable extrathoracic UAO. 
c) Spirometry report shows fixed UAO. 

Spirometry Exercise 19

A 42-yearold male, presented with dyspnoea and stridor. On examination, there were no
positive findings except stridor. Chest x-ray and CT thorax showed a narrowing of the trachea.
Fiberoptic bronchoscopy showed a circumferential mass along the tracheal lumen. Histology
showed squamous cell carcinoma.

Diagnosis: Primary squamous cell carcinoma of the trachea.

a) Spirometry report shows variable intrathoracic UAO. 

b) Spirometry report shows variable extrathoracic UAO. 
c) Spirometry report shows fixed UAO. 

56
Spirometry Exercise 20

A 73-year-old male complained of snoring, excessive daytime sleepiness and choking during
sleep. His body mass index (BMI) was 34 kg/m2. Polysomnography (PSG) showed apnoea-
hypopnoea index (AHI) of 23 and oxygen desaturation during sleep.

Diagnosis: Obstructive sleep apnoea (OSA).

a) Spirometry report shows variable intrathoracic UAO. 

b) Spirometry report shows variable extrathoracic UAO. 
c) Spirometry report shows fixed UAO. 

Spirometry Exercise 21

A 44-year-old man, atopic (history of asthma in mother and eczema in sister) and a (24 pack
years) ex-smoker, presented with a case of cough, dyspnoea, and wheeze since 5 years. On
examination, there was wheeze present. Chest X-Ray (CXR) was clear.

57
Provisional Diagnosis: Bronchial asthma (BA), or COPD.

Test Predicted Bronchodilator %Change

Before After
FVC 3.17 L 1.03 (32%) 1.32 (42%)
FEV1 2.78 L 0.45 (55%) 0.54 (66”/o) (+21%, 90 ml)
FE1/FVC 43% 41%
PEF 7.59 L/s 4.03 L/sec 4.34 L/sec

a) Obstructive abnormality with good bronchodilator reversibility. Yes/No

b) Mixed obstructive and restrictive abnormality. Yes/No
c) The patient should be treated for COPD. Yes/No

Spirometry Exercise 22

A 48-year-old man, who was a smoker (22 pack years), presented with a history of cough and
progressive dyspnoea since 5 years. On examination, there was wheeze present. CXR was
normal.

58
Provisional Diagnosis: COPD.

Test Predicted Bronchodilator %Change

Before After
FVC 4.55 L 3.97 (87%) 4.18 (92%)
FEV1 3.69 L 2.43 (66%) 2.45 (67%) (+1%, 20 ml)
FEV1/FVC 63% 60%
PEF 7.5 L/sec 5.89 L/sec 5.53 L/sec

(a) Spirometry shows obstructive abnormality with poor reversibility. Yes/No

(b) COPD severity is of Class 1 as per the GOLD Guidelines. Yes/No
(c) The first line of treatment is bronchodilators. Yes/No

Spirometry Exercise 23

A 50-year-old man, atopic and a non-smoker, was evaluated for recurrent right-sided
pneumothorax. He had been through two episodes of pneumothorax, both of which required
intercostal tube drainage. Additionally, he had a history of allergic rhinitis since childhood.
CXR was clear.

59
Spirometry (performed 1 month after full lung expansion along with intercostal tube
drainage during the second episode of pneumothorax) was as shown below:

Test Predicted Bronchodilator %Change

Before After
FVC 4.79 L 2.61 (55%) 2.69 (56%)
FEV1 3.84 L 1.71 (45%) 1.92 (50%) (+12%, 210 ml)
FEV1/FVC 66% 71%
PEF 9.11 L/sec 4.67 L/sec 5.75 L/sec

(a) Patient had secondary spontaneous pneumothorax due to asthma. Yes/No

(b) BA is of severe persistent grade as per the GINA guidelines. Yes/No
(c) Low FVC is explained by the severity of the obstruction. Yes/No

Spirometry Exercise 24

A 61-year-old man was referred for dry cough and progressive dyspnoea since 6 months.
On examination, there were bibasilar, fine end inspiratory crackles. CXR showed bibasilar
reticular opacities. High resolution computerised tomography (HRCT) showed ground-glass
opacities and interstitial thickening in the lower lobes.

60
Provisional Diagnosis: Idiopathic interstitial pneumonia (lIP) most likely, non-specific
interstitial pneumonia (NSIP).
Treatment was initiated with prednisolone, as a single daily dose of 1 mg/kg of body
weight. Reassessment after 2 months showed a marked improvement in the symptoms, and
spirometry was repeated. The results were as shown below:

Test Predicted Before OCS After OCS %Change

FVC 2.94 L 1.77 (60%) 2.07 (70%) (+ 300 ml)
FEV1 2.36 L 1.59 (67%) 1.7 (60%)
FEV1/FVC 90% 85%
PEF 6.98 L/sec 8.19 L/sec 8.12 L/sec

a) Spirometry report shows restrictive abnormality. Yes/No

b) Spirometry is consistent with interstitial lung disease. Yes/No
c) Spirometry shows a good response to corticosteroids. Yes/No

Spirometry Exercise 25

A 48-year-old man presented with a history suggestive of allergic rhinitis since 6 years. He
had also developed a dry cough since 4-5 months. There was no dyspnoea or wheeze. CXR
was clear.

61
Provisional Diagnosis: Persistent allergic rhinitis with cough-variant asthma.
Spirometry was normal. Spirometry was repeated after 4 weeks of inhaled corticosteroids (ICS)
and long-acting beta2-agonists (LADAs). Another spirometry was repeated after the omission
of LADAs for 48 hours.

Test Predicted Baseline After 4 wks of After omission of

ICS+LAIAs LABAs for 48 hours
FVC 3.21 L 2.59 (81%) 2.84 (88%) 2.50 (78%)
FEV1 2.71 L 2.20 (81%) 2.65 (98%) 2.18 (80%)
FE1/FVC 85% 93% 87%
PEF 7.50 L/sec 7.62 L/sec 8.68 L/sec 7.80 L/sec

a) Baseline study shows obstructive abnormality. Yes/No

b) Spirometry done after ICS+LABAs and omission of LABAs confirm asthma. Yes/No
c) Treatment must be continued long-term. Yes/No

Spirometry Exercise 26

A 45-year-old man was referred for an assessment of dyspnoea on exertion. He had a history
of severe kyphoscoliosis since childhood. In addition, he had symptoms of sleep-disordered
breathing (SOB) since 4 years. His chest radiograph confirmed kyphoscoliosis and the Cobb’s
angle was 90°. Room air saturation was 87%.
Provisional Diagnosis: Severe kyphoscoliosis with SOB (Quasimodo’s syndrome).

62
 Test Predicted Bronchodilator %Change
Before After
FVC 3.19 L 0.84 (26%) 0.87 (27%)
FEV1 2.70 L 0.68 (25%) 0.72 (27%) (+6%, 40 ml)
FEV1/ FVC 82% 83%
PEF 7.49 L/sec 2.21 L/sec 2.96 L/sec

a) Flow volume loop (FVL) shows upper airways obstruction. Yes/No

b) Spirometry shows restrictive abnormality. Yes/No
c) The patient should be evaluated further with a sleep study. Yes/No

63
Spirometry Exercise 27

A 15-year-old asthmatic boy presented with poorly controlled asthma despite optimum
therapy. He had received several courses of oral corticosteroids, but all without much
symptomatic relief. CXR was normal.
Provisional Diagnosis: Poorly controlled asthma.
The spirometry was performed and the FVL was recorded.

64
 Pre Test Comments: PRE-BRONCH POST-BRONCH
Post Test Comments:
Pred. Actual %Pred. Actual %Pred. %Change
SPIROMETRY
FVC (L) 3.60 1.77 49 1.98 55 12
FEY 0.5 (L) 1.14 1.03 -10
FEV1 (L) 3.09 1.72 56 1.65 53 -4
FEV3 (L) 4.59 1.77 39 1.97 43 11
FEV1/ FVC (%) 88 97 111 83 95 -14
FEF25% (L/sec) 8.08 2.59 32 2.02 25 -22
FEF50% (L/sec) 6.03 2.02 34 1.92 32 -5
FEF75% (L/sec) 3.61 1.34 37 1.35 37 0
FEF25-75% (L/sec) 3.49 1.90 54 1.81 52 -5
FEFMax (L/sec) 8.87 2.79 31 2.11 24 -24
FIVC (L) 1.55 1.99 29
FIF50% (L/sec) 0.80 0.50 -37
FIFMax (L/sec) 0.92 0.66 -29
FET25-75% (sec) 0 0 5

(a) FVL shows upper airways obstruction. Yes/No

(b) Spirometric indices confirm upper airways obstruction. Yes/No
(c) Indirect laryngoscopy will confirm the diagnosis. Yes/No

65
Spirometry Exercise 28

An 18-year-old female came in for a pre-operative assessment of goitre.

She complained of dyspnoea in the supine position.
Spirometry report, with the FVL reconstruction in a sitting position, was normal. Spirometry,
with the FVL recorded in the supine position, was as shown below:

a) FVL in the supine position shows variable intrathoracic upper

airway obstruction (UAO). Yes/No
b) Presence of UAO in the supine position indicates surgery for goitre. Yes/No
c) FVL must be performed in the specific position in which the patient
complains of having dyspnoea. Yes/No

66
Spirometry Exercise 29

A 62-year-old woman presented with cough, haemoptysis, and dyspnoea. Examination

showed right lung collapse.
Spirometry was performed and the FVL recorded was as shown below:

67
 Pre Test Comments: PRE-BRONCH POST-BRONCH
Post Test Comments:
Pred. Actual %Pred. Actual %Pred. %Change
SPIROMETRY
FVC (L) 3.79 1.89 50 1.89 50 0
FEY 0.5 (L) 2.68 1.05 39 1.08 40 4
FEV1 (L) 3.05 1.36 45 1.38 45 1
FEV3 (L) 3.88 1.89 49 1.89 49 0
FEV1/ FVC (%) 81 72 90 73 91 1
FEF25% (L/sec) 7.00 3.04 43 3.61 52 19
FEF50% (L/sec) 4.24 0.96 23 1.05 25 9
FEF75% (L/sec) 1.56 0.47 30 0.43 27 -9
FEF25-75% (L/sec) 3.56 0.94 26 0.95 27 1
FEFMax (L/sec) 7.98 4.32 54 4.21 53 -3
FIVC (L) 4.06 2.00 49 1.98 49 -1
FIF50% (L/sec) 4.85 1.80 22 1.44 30 33
FIFMax (L/sec) 3.76 1.52 40 2.83 75 86
FET25-75% (sec) 1 1 -1

a) FVL shows a specific: type of UAO. Yes/No

b) Bronchoscopy will confirm the site and nature of the obstruction. Yes/No
c) Calculated value of the predicted post-operative (ppo) FEV1
suggests suitability for lung resection surgery. Yes/No

68
Spirometry Exercise 30

A 48-year-old woman presented with severe exertional dyspnoea. Her body mass index (BMI)
was 65 kg/m2.
Spirometry was performed and the results were as shown below:

69
 Pre Test Comments: PRE-BRONCH POST-BRONCH
Post Test Comments:
Pred. Actual %Pred. Actual %Pred. %Change
SPIROMETRY
FVC (L) 2.73 0.80 29 0.94 50 0
FEV 0.5 (L) 1.99 0.60 30 0.77 40 4
FEV1 (L) 2.32 0.70 30 0.87 45 1
FEV3 (L) 2.87 0.79 28 0.94 49 0
FEV1/ FVC (%) 80 88 110 92 91 1
FEF25% (L/sec) 5.39 3.70 69 5.23 52 19
FEF50% (L/sec) 3.76 0.98 26 2.97 25 9
FEF75% (L/sec) 1.54 0.32 21 0.90 27 -9
FEF25-75% (L/sec) 3.23 0.87 27 2.42 27 1
FEFMax (L/sec) 5.98 4.07 68 5.27 53 -3
FIVC (L) 3.01 0.75 25 1.01 49 -1
FIF50% (L/sec) 4.21 1.61 38 1.70 30 33
FIFMax (L/sec) 4.62 1.84 40 1.86 75 86
FET25-75% (sec) 0 0 -64

Enter the relevant parameters in the table below and interpret the report.

Test Predicted Bronchodilator %Change

Before After
FVC
FEV1
FEV1/ FVC%
PEF

a) FVL shows upper airways obstruction. Yes/No

b) FVL and spirometry results show moderate restrictive abnormality. Yes/No
c) The patient’s symptoms, and the spirometric abnormality are
due to morbid obesity. Yes/No

70
Spirometry Exercise 31

A 20-year-old woman suffered from cough, dyspnoea and wheeze since childhood. For the
past 4- 5 years she had developed dyspepsia and retrosternal pain following meals. This was
associated with worsening of dyspnoea and wheeze. She was atopic as indicated by history of
eczema in her mother. On examination, there was wheeze present. CXR was clear.
Provisional Diagnosis: Bronchial asthma with gastroesophageal reflux disorder (GERD).

71
 Pre Test Comments: PRE-BRONCH POST-BRONCH
Post Test Comments:
Pred. Actual %Pred. Actual. %Pred. %Change
SPIROMETRY
FVC (L) 2.22 1.25 56 1.76 79 40
FEV 0.5 (L) 1.69 0.79 47 1.00 59 26
FEV1 (L) 1.86 1.01 55 1.29 69 27
FEV3 (L) 2.36 1.24 52 1.65 70 33
FEV1/ FVC 79 81 103 73 93 -1 0
FEV3/ FVC 94
FEF25% (L/sec) 4.98 2.24 45 3.15 63 40
FEF50% (L/sec) 3.41 1.01 30 1.91 56 89
FEF75% (L/sec) 1.30 0.44 34 1.00 77 127
FEF25- 75% (L/sec) 2.92 0.95 33 1.76 60 85
FEFMax (L/sec) 5.36 2.90 54 3.65 68 26
FIVC (L) 2.51 1.23 49 1.65 66 34
FIF50% (L/sec) 4.42 2.68 78 2.59 76 -3
FIFMax (L/sec) 3.83 2.70 70 2.75 72 2
FET25-75% (sec) 1 0 - 45

The spirometric parameters are tabulated in a simplified manner as below.

Interpret the spirometry.

Test Predicted Bronchodilator %Change

Before After
FVC 2.22 L 1.25 (56%) 1.76 (79%)
FEV1 1.86 L 1.01 (55%) 1.29 (69%) (+27%, 280 ml)
FEV1/FVC% 81% 73%

24 hours esophageal pH monitoring was performed and the report is as shown on the next
page.

72
Parameter Value Weight Score
% total time pH <4 3.30 (pv - 0.5)/1.4 2.00
% upright time pH <4 9.52 (pv - 1.2)/2.3 3.62
% supine tome pH <4 2.67 (pv + 0.4)/1.0 3.07
No. of episodes > = 30 sec. 25.00 (pv - 18)/12.8 0.55
Longest episode > = 5 min 1.00 (pv + 0.2)/1.2 1.00
Longest episode (min) 9.07 (pv -5.7)/7.9 0.43
DeMeester Score 10.66

73
Spirometry Exercise 32

A 73-year-old male, 32-pack-year current smoker gave history of cough and progressive
breathlessness since 15 years. He had dyspnoea on walking on flat ground. His body mass
index (Weight in Kg I Height in m~ was 15.63 Kg/m". His 6 minute walk distance was <150
meters. On examination, there was wheeze present. CXR showed emphysema.
Provisional Diagnosis: COPD.

74
 Pre Test Comments PRE-BRONCH POST-BRONCH
Post Test Comments
Pred. Actual %Pred. Actual %Pred. %Change
SPIROMETRY
FVC (L) 3.06 1.41 46 1.53 50 8
FEV 0.5 (L) 2.25 0.32 14 0.36 16 15
FEV1 (L) 2.36 0.48 20 0.56 24 17
FEV1 (L) 3.15 0.90 29 1.03 33 15
FEV1/FVC (%) 79 34 43 37 47 8
FEF25% (L/sec) 6.24 0.34 5 0.45 7 34
FEF50% (L/sec) 3.54 0.20 6 0.28 8 42
FEF75% (L/sec) 1.02 0.14 14 0.18 18 26
FEF25-75% (L/sec) 2.79 0.20 7 0.26 9 31
FEFMax (L/sec) 6.96 1.36 19 1.66 24 22
FIVC (L) 3.33 1.46 44 1.61 48 11
FIF50% (L/sec) 4.46 1.14 25 1.22 2 7
FIFMax (L/sec) 3.38 1.28 38 1.49 44 16
FET25-75% (sec) 4 3 -23

The spirometric parameters are tabulated in a simplified manner as below. Interpret the
spirometry.

Test Predicted Bronchodilator %Change

Before After
FVC 3.06 L 1.41 (46%) 1.53 (50%)
FEV1 2.36 L 0.48 (24%) 0.56 (24%) (+17%, 80 ml)
FEV1/FVC% 34% 37%

75
His DEXA (dual energy x-ray absorption) scan was performed to assess bone mineral density
(BMD) for osteoporosis and to assess fat free mass index (FFMI).

Patient
Name: Height: 160.0 cm
Patient ID: 17203 Weight 40.0 kg
Date of Birth: 08104/1935 Exam Dale: 23/01/2008
Gender: Male BMD Device: GE Medical Systems Prodigy
Indications: None
Fractures: None
Treatments: None

Results
Scan Type Region Measured Age BMD T-score z-score
2
Left Forearm Radius Total 23/01/2008 72.7 0.313 g/cm - 5.4 -4.5
2
AP Splne L1·14 23/01/2008 72.7 0.705 g/cm -4.3 -2.5
2
Dual Femur Total Mean 23/01/2008 72.7 0.688 g/cm -3.1 -1.3
2
Total Body Total 23/01/2008 72.7 0.840 g/cm -4.8 -2.5

Assessment:
World Health Organisation - Definition of Osteoporosis and Osteopenia for White Women:
Normal : T-score at or above -1 SD
Osteopenia : T-score between - 1 and -2.5 SD
Osteoporosis : T-Score at or below - 2.5 SD
Established Osteoporosis : T·Score at or below ·2.5 SD plus fragility fractures
His DEXA measured Fat Free Mass Index (FFMI) was 13 Kg/m2.
Why is it important to measure BMD and FFMI in cases of COPD? What is the BODE index?

76
Spirometry Exercise 33

A 20-year-old man was referred for preoperative assessment prior to spine surgery for
kyphoscoliosis. Spirometry performed initially using his height and later arm span for
calculating predicted values which are shown below and next page.

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments
Pred. Actual %Pred. Actual %Pred. %Change.
SPIROMETRY
FVC (L) 4.63 2.76 60 2.83 61 3
FEV 0.6 (L) 3.27 1.92 59 2.24 68 17
FEV1 (L) 3.97 2.66 67 2.76 70 4
FEV1 (L) 4.93 2.75 56 2.83 57 3
FEV1/FVC (%) 86 97 112 98 114 1
FEF25% (L/sec) 7.92 4.00 51 5.43 89 36
FEF50% (L/sec) 5.20 3.28 63 3.94 76 21
FEF75% (L/sec) 2.37 2.48 105 3.03 128 22
FEF25-75% (L/sec) 4.88 3.30 68 3.98 81 20
FEFMax (L/sec) 9.33 5.94 64 6.63 71 12
FIVC (L) 5.04 2.79 55 3.08 61 10
FIF50% (L/sec) 5.81 3.21 55 4.91 84 53
FIFMax (L/sec) 4.62 3.95 85 5.01 108 27
FET25-75% (sec) 0 0 - 14

77
 Pre Test Comments PRE-BRONCH POST-BRONCH
Post Test Comments
Pred. Actual %Pred. Actual %Pred. %Change.
SPIROMETRY
FVC (L) 4.52 2.76 61 2.83 63 3
FEV 0.6 (L) 3.21 1.92 60 2.24 70 17
FEV1 (L) 3.88 2.66 89 2.76 71 4
FEV1 (L) 4.83 2.75 57 2.83 59 3
FEV1/FVC (%) 86 97 112 98 113 1
FEF 25% (L/sec) 7.82 4.00 51 5.43 69 36
FEF 50% (L/sec) 5.13 3.28 64 3.94 77 21
FEF 75% (L/sec) 2.32 2.48 107 3.03 131 22
FEF 25- 75% (L/sec) 4.83 3.30 68 3.98 82 20
FEF Max (L/sec) 9.21 5.94 64 8.83 72 12
FIVC (L) 4.93 2.79 57 3.08 63 10
FIF 50% (L/sec) 5.81 3.21 55 4.91 84 53
FIF Max (L/sec) 4.60 3.95 86 5.01 109 27
FET 25- 75% (sec) 0 0 - 14

Test Predicted Predicted Observed Values using Values using

using height using arm values height arm span
span
FVC 4.63 L 4.52L 2.78 60% pred 61% pred
FEV1 3.97 L 3.88 L 2.66 67% pred 69% pred
FEV1/ FVC% 97% 97%

Interpret the spirometry results. When and why is arm span used to calculate the predicted
values?

78
Spirometry Exercise 34

A 39-year-old woman was referred for dry cough and progressive dyspnoea since 3 years.
On examination, there were fine end inspiratory crackles. Chest X-Ray showed bilateral
reticula-nodular opacities. Computerised Tomography (CT) thorax showed bilateral uniformly
enhancing lymph nodes in the hilar and right paratracheal regions. Lung windows showed
peribronchial interstitial nodules. Treatment was initiated with oral corticosteroids (OCS),
prednisolone in a dose of 0.5 mg/Kg day. Reassessment after 4 weeks showed marked
improvement in symptoms, spirometry was repeated and results were as shown below and
on next page.
Provisional Diagnosis: Pulmonary sarcoidosis (Type 2).

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments
Pred. Actual %Pred. Actual %Pred. %Change.
SPIROMETRY
FVC (L) 3.01 1.59 53 1.57 52 -1
FEV 0.5 (L) 2.18 0.82 38 0.99 48 21
FEV1 (L) 2.59 1.09 42 1.27 49 18
FEV3 (L) 3.15 1.50 48 1.57 50 5
FEV1/FVC (%) 82 69 84 81 99 17
FEV3/FVC (%) 95 100 6
FEF25% (L/sec) 5.65 2.01 36 3.54 63 76
FEF50% (L/sec) 4.01 0.79 20 1.21 30 53
FEF75% (L/sec) 1.77 0.33 18 0.50 28 54
FEF25-75% (L/sec) 3.54 0.69 20 1.08 31 56
FEFMax (L/sec) 6.30 3.66 58 4.30 68 18
FIVC (L) 3.27 1.49 48 1.30 40 - 13
FIF50% (L/sec) 3.81 2.32 81 2.14 56 ·8
FIFMax (L/sec) 4.13 2.66 64 2.26 55 ·15 · 15
FET25-75% (sec) 1 1 - 37

79
 Pre Test Comments PRE·BRONCH POST·BRONCH
Post Test Comments
Pred. Actual %Pred. Actual %Pred. %Change.
SPIROMETRY
FVC (L) 3.01 1.82 61 1.91 63 5
FEV 0.5 (L) 2.18 1.04 48 1.23 58 18
FEV1 (L) 2.59 1.33 51 1.55 60 17
FEV3 (L) 3.15 1.74 55 1.90 61 10
FEV1/FVC (%) 82 73 89 81 99 12
FEF25% (L/sec) 5.65 3.23 57 4.63 82 43
FEF50% (L/sec) 4.01 1.11 28 1.79 45 61
FEF75% (L/sec) 1.77 0.38 22 0.63 36 64
FEF25-75% (L/sec) 3.54 0.90 25 1.55 44 72
FEFMax (L/sec) 6.30 4.22 67 4.81 76 14
FIVC (L) 3.27 1.87 57 2.06 63 10
FIF50% (L/sec) 3.75 2.13 57 2.07 55 -3
FIFMax (L/sec) 4.07 2.59 64 2.16 53 - 17
FET25-75% (sec) 1 1 - 42

Test Predicted Before OCS After OCS %Change

FVC 3.01 L 1.59 (53%) 1.82 (61%) +14% 230 ml
FEV1 2.59 L 1.09 (42%) 1.33 (51%)
FEV1/FVC% 69% 73%

Interpret the baseline and post steroid spirometry reports.

What is the response to steroids?

80
Spirometry Exercise 35

A 70-year-old man gave history suggestive of allergic rhinitis and bronchial asthma for 10
years. He had been evaluated in 2000 and advised inhaled corticosteroids and long acting
beta agonists. However, he did not initiate therapy as advised and took only bronchodilators
for symptom control. He followed up in 2008 with persistent symptoms and spirometry was
repeated. The spirometry reports of 2000 and 2008 are shown below.
2000

Test Predicted Bronchodilator %Change

Before After
FVC 3.61 L 2.25 (62%) 2.73 (76%)
FEV1 2.85 L 1.35 (47%) 1.81 (64%) (+33%, 460ml)
FEV1/FVC% 60% 66%

Test Predicted Bronchodilator %Change

Before After
FVC 3.38 L 2.51 (74%) 3.44 (102%)
FEV1 2.59 L 1.13 (44%) 1.67 (65%) (+47%, 540ml)
FEV1/FVC% 44% 49%
Interpret the spirometry reports

81
Spirometry Exercise 36

A 31-year-old man complained of allergic rhinitis with nasal polyps and bronchial asthma
since 4-5 years. He also had hypersensitivity to aspirin. He had been taking treatment from
the family physician on and off. However, since the past week he had developed troublesome
nocturnal symptoms.
Provisional Diagnosis: Asthma, nasal polyposis and aspirin sensitivity (Samter’s triad).
Initial Spirometry

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments Actual Pred. % Pred. Actual % Pred. % Chng.
SPIROMETRY
FVC (L) 2.80 4.19 67 3.19 76 14
FEV1 (L) 1.68 3.58 47 2.23 62 33
FEV1/FVC (%) 60 82 73 70 85 16
FEF25% (L/sec) 1.97 7.48 26 3.21 43 63
FEF75% (L/sec) 0.43 2.08 21 1.21 58 182
FEF25-75% (L/sec) 0.94 4.51 21 1.95 43 107
FEFMax (L/sec) 4.09 8.76 47 4.85 55 19
FIVC (L) 2.94 3.57 26
FIFMAX (L/sec) 4.49 -25

82
Test Predicted Bronchodilator % Change
Before After
FVC 4.19 L 2.80 (67%) 3.19 (76%)
FEV1 3.58 L 1.68 (47%) 2.23 (62%) (+33%, 550ml)
FEV1/FVC% 60% 70%
After 2 weeks of oral corticosteroids, salmeterol-fluticasone (SFC) by MDI and rescue
salbutamol.

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments Actual Pred. % Pred. Actual % Pred. % Chng.
SPIROMETRY
FVC (L) 3.70 4.19 88 3.79 90 2
FEV1 (L) 3.06 3.58 86 3.09 86 1
FEV1/FVC (%) 83 82 101 81 99 -2
FEF25% (L/sec) 4.95 7.48 66 4.75 64 -4
FEF75% (L/sec) 1.67 2.08 80 1.68 81 1
FEF25-75% (L/sec) 2.89 4.51 64 2.90 64 0
FEFMax (L/sec) 7.58 8.76 86 7.22 82 -5
FIVC (L) 3.54 3.69 4
FIF MAX (L/sec) 4.88 5.41 11

83
 Test Predicted Bronchodilator % Change
Before After
FVC 4.19 L 3.70 (88%) 3.79 (90%)
FEV1 3.58 L 3.06 (86%) 3.09 (86%) (+1%, 10ml)
FEV1/FVC% 83% 81%
Interpret spirometry reports. Comment on the diagnosis and response to treatment.

Spirometry Exercise 37

A 36-year-old man had been diagnosed to have “COPD” due to symptoms suggestive of chronic
airway obstruction and spirometry showing “irreversible airway obstruction.” As he had never
smoked the etiology was attributed to “environmental pollution.” He had received treatment
for the same but continued to worsen. CXR was normal. On more detailed questioning, he
gave history of asthma in his mother and history suggestive of urticarial in self on and off. His
total serum immunoglobulin (lg) E-levels were elevated.
Provisional diagnosis: Chronic airway obstruction, most likely bronchial asthma.
His initial spirometry report is as shown.
Pre Test Comments PRE-BRONCH POST-BRONCH
Post Test Comments Pred. Actual % Pred. Actual % Pred. % Chng.
SPIROMETRY
FVC (L) 4.06 1.28 31 1.34 33 5
FEV 0.5 (L) 2.84 0.53 19 0.53 19 2
FEV1 (L) 3.43 0.75 22 0.77 23 3
FEV3 (L) 4.18 1.25 30 1.26 30 0
FEV1/FVC (%) 84 59 70 58 69 -1
FEV3/FVC (%) 98 94 -4
FEF25% (L/sec) 7.33 0.81 11 0.84 11 4
FEF50% (L/sec) 4.67 0.46 10 0.47 10 2
FEF75% (L/sec) 1.95 0.26 13 0.28 14 5
FEF25-75% (L/sec) 4.29 0.43 10 0.45 10 3
FEFMax (L/sec) 8.55 2.97 35 2.97 35 0
FIVC (L) 4.30 1.23 29 1.27 30 3
FIF50% (L/sec) 5.34 2.07 39 2.31 43 12
FIFMAX (L/sec) 4.19 2.46 59 2.68 64 9
FET25-75% (sec) 1 1 2

84
In the absence of bronchodilator reversibility and a clinical diagnosis of bronchial asthma a
trial of oral corticosteroids was given for a period of 2 weeks and the repeat spirometry is as
shown below.

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments Pred. Actual % Pred. Actual % Pred. % Chng.
SPIROMETRY
FVC (L) 4.08 1.81 44 2.35 57 29
FEV 0.5 (L) 2.85 0.72 25 0.80 28 10
FEV1 (L) 3.46 1.04 30 1.16 34 12
FEV3 (L) 4.21 1.61 38 1.81 43 12
FEV1/FVC (%) 84 57 68 50 59 -13
FEV3/FVC (%) 82
FEF25% (L/sec) 7.36 1.20 16 1.53 21 27
FEF50% (L/sec) 4.70 0.62 13 0.82 17 33
FEF75% (L/sec) 1.98 0.27 13 0.41 21 54
FEF25-75% (L/sec) 4.34 0.56 13 0.77 18 38
FEFMax (L/sec) 8.59 3.05 35 3.01 35 -1
FIVC (L) 4.32 1.98 46 2.06 48 4
FIF50% (L/sec) 5.37 2.92 54 4.06 76 39
FIFMAX (L/sec) 4.22 3.23 77 4.49 107 39
FET25-75% (sec) 2 1 -27

85
 Test Predicted Bronchodilator % Change
Before OCS After OCS
FVC 4.08 L 1.28 (31%) 1.81 (44%)
FEV1 3.46 L 0.75 (22%) 1.04 (30%) 38%, 290ml
FEV1/FVC% 59% 57%
Interpret spirometry reports. Comment on the diagnosis based on oral corticosteroid
response.

86
Spirometry Exercise 38

A 48-year-old man, 25-pack-year smoker presented with symptoms of cough, dyspnoea and
wheeze for the past 5 years. Examination was unremarkable except presence of wheeze on
chest auscultation. CXR was normal. HRCT showed centrilobular emphysema.
Clinical diagnosis: COPD
His spirometry with flow volume loop is shown below.

Pre Test Comments PRE-BRONCH POST-BRONCH

Post Test Comments Actual Pred. % Pred. Actual % Pred. % Chng.
SPIROMETRY
FVC (L) 2.80 4.19 67 3.19 76 14
FEV1 (L) 1.68 3.58 47 2.23 62 33
FEV1/FVC (%) 60 82 73 70 85 16
FEF 25% (L/sec) 1.97 7.48 26 3.21 43 63
FEF 75% (L/sec) 0.43 2.08 21 1.21 58 182
FEF 25-75% (L/sec) 0.94 4.51 21 1.95 43 107
FEF Max (L/sec) 4.09 8.76 47 4.85 55 19
FIVC (L) 2.84 3.57 26
FIF MAX (L/sec) 4.49 3.35 -25

Interpret the spirometry reports. Does presence of good reversibility mean that diagnosis is
bronchial asthma? What is the severity of the disease based on spirometry?

87
Spirometry Exercise 39

A 66-year-old man, 10-pack-year smoker was referred for routine medical check-up. He
complained of occasional cough and dyspnoea. On examination there were no abnormal
findings. Spirometry was performed and the report is as shown below.

Tests Results Ref value Measured

Variable Abbr Unit Ecsc_m Pre test Abs % ref
Forced vital capacity FVC L 4.02 3.32 83
Forced exp. Volume at 1.0s FEV1 L 3.26 2.78 85
Forced exp. Volume at 6.0s FEV6 L 4.02 3.31 82
FEV1 / FVC FEV1% (FVC) % 78.06 83.77 107
Peak expiratory flow PEF L/s 8.28 9.74 118
Forced exp. Flow 50% VC FEF50 L/s 4.44 4.85 109
Forced exp. Flow 75% VC FEF75 L/s 1.72 1.20 70
Forced exp. Flow 25-75% VC FEF25-75% L/s 3.77 3.44 91
Extrapolated volume EV L 0.13
Lung age LAGE a 67.00
Interpret the spirometry. Comment on the MMFR or Forced expiratory flow 25-75%? What
is FEV6? What is “lung age” (LAGE)?

88
Spirometry Exercise 40

A 50-year-old man with history of 35-pack-year smoking came for routine health check-
up. He was asymptomatic and there was no abnormality detected on clinical examination.
Spirometry performed show.

Pre Test Comments PRE-BRONCH

Post Test Comments Actual Pred. % Pred.
SPIROMETRY
FVC (L) 3.05 4.34 70
FEV1 (L) 2.54 3.45 74
FEV1/FVC (%) 83 77 108
FEF25% (L/sec) 6.56 7.52 87
FEF75% (L/sec) 0.96 1.80 53
FEF25-75% (L/sec) 3.18 3.71 86
FEFMax (L/sec) 9.18 8.55 107
FIVC (L) 0.03
FIF MAX (L/sec) 7.38
LUNG VOLUMES
SVC (L) 3.07 4.34 71
IC 1 (L) 2.83 3.45 82
ERV (L) 0.24 0.89 27
TGV (L) 2.20 3.53 62
RV (Pleth) (L) 1.96 2.31 85
TLC (Pleth) % 5.03 6.98 72
RV/TLC (Pleth) (%) 39 36 108
Trapped Gas (L)
AIRWAYS RESISTANCE
Raw (cmH2O/L/s) 0.75 2.24 33
Gaw (L/s/cmH2O) 1.75 1.03 167
sRaw (cmH2O*s) 1.93 <4.76
sGaw (1cmH2O*s) 0.67 0.08 837
Interpret the Spirometry report. What is the explanation for normal spirometry despite
history of chronic heavy smoking?

89
Answers to Test Exercise

1A: Without any clinical information and using the flow-chart, the spirometry interpretation is
severe restrictive abnormality.
1B: With clinical information and post-bronchodilator test, the interpretation now is severe
obstructive abnormality with good BDR. The high FEV1/FVC ratio (84%) in the baseline test is
due to “false normalisation”. This is proved by the FEV1/FVC ratio reducing (63%) in the post-
bronchodilator test.
The absence of clinical information and post-bronchodilator test resulted in the incorrect
interpretation in Test Exercise 1a.
2: Obstructive abnormality with good BDR. Asthma severity is mild asthma by spirometric FEV1
criteria as per GINA guidelines.
3: Obstructive abnormality with poor BDR. The low FVC is due to air trapping and not indicative
of restrictive abnormality in the absence of any clinic-radiological evidence of disease
causing restriction.
COPD severity is severe (<50%) by spirometry FEV1 criteria as per GOLD guidelines.
4: Obstructive abnormality with good BDR. Low FVC in baseline test due to air trapping
evident by increase in FVC after bronchodilators. The LOW FVC is not indicative of restrictive
abnormality as there is no clinic-radiological evidence of any disease causing restriction.
Also, low FVC due to restrictive abnormality will remain unchanged after bronchodilators.
Asthma severity is severe asthma by spirometric FEV1 criteria as per GINA guidelines.
5: With clinic-radiological correlation, spirometry is suggestive of mild restrictive abnormality.
6: Normal spirometry. No, spirometry was not required in this case for pre-operative assessment
as: a) there are no risk factors, symptoms or radiological findings for pulmonary disease and
b) The site of surgery is distant from the thorax – both being factors, which predict post-
operative pulmonary complications.
7: Normal spirometry. Predicted post-operative (ppo) FEV1, is greater than 1 litre, hence patient
is fit for the planned left lower lobectomy.
8: FV loop suggestive of variable extrathoracic upper airway obstructive.
9: FV loop suggestive of fixed upper airway obstruction.
10: FV loop suggestive of variable intrathoracic upper airway obstruction. Although the
inspiratory portion of the loop is incomplete, making the flow volume loop technically
unacceptable, it is adequate to interpret variable intrathoracic UAO.
11. Spirometry Exercise 11: (a, c). FEV1/FVC 63% indicates obstructive abnormality, while 20%,
310 ml improvement in FEV1 following bronchodilator indicates good bronchodilator
reversibility. Symptoms of bronchial asthma developed after starting  blockers, hence

90
 spirometry should be repeated after discontinuation of the same. In addition patient needs
to be treated for asthma.
12. Spirometry Exercise 12: (a). FEV1/FVC 58% indicates obstructive abnormality. There is poor
bronchodilator reversibility improvement in FEV1 following bronchodilator, only 6 ml (4%)
consistent with diagnosis of COPD.
13. Spirometry Exercise 13: (b) FVC% (obs/pred) 59% suggests restrictive abnormality. FEV1/FVC
85% and lack of improvement following bronchodilator conclusively excludes coexistent
obstructive abnormality.
14. Spirometry Exercise 14: (a, c). FEV1/FVC 69% indicates obstructive abnormality, while 20%,
550 ml improvement in FEV1 following oral steroids indicates good reversibility. There is no
restrictive abnormality as FVC% (obs/pred) is 73%. Spirometry determined asthma severity is
severe asthma as FEV1% (obs/pred) is 59% i.e. <60%.
15. Spirometry Exercise 15: (b, c) Although, FEV1/FVC% is 80%, improvement in FEV1 by 57%,
260 ml following bronchodilator i.e. good bronchodilator reversibility indicates obstructive
abnormality. Low FVC of 31% may be misread as associated restrictive abnormality. However,
absence of any disease likely to cause restrictive abnormality and improvement in FVC to
67% in the post bronchodilator study suggests that low FVC in the baseline study was due
to air trapping associated with severe airway obstruction. This has also resulted in “false
normalisation” of the FEV1/FVC% (80%) in the baseline study, which shows “paradoxical fall”
to 62% (due to greater increase in FVC than FEV1,) following bronchodilator.
16. Spirometry Exercise 16: (b). Using the “rule of five”, 1/5th function is attributed to each lobe.
Thus, for FEV1, 1/5 of 2.5 L = 0.5 L for each lobe. Calculation of predicted post-operative
(ppo) FEV1 is 2.5 L - 0.5 L = 2 L.
17. Spirometry Exercise 17: (a). The decline in FEV1 between 2000 and 2006 is 260 ml i.e. 260/6
= 43 ml per year. The annual decline in COPD patients is >70 ml per year, hence serial
spirometry in this case does not suggest the diagnosis of COPD.
18. Spirometry Exercise 18: (b) Spirometry report shows flattening of the inspiratory (lower)
portion of the flow volume loop, hence variable extrathoracic UAO.
19. Spirometry Exercise 19: (c) Spirometry report shows flattening of the inspiratory and
expiratory portions of the flow volume loop (box like loop), hence fixed UAO.
20. Spirometry Exercise 20: Spirometry report shows flattening of the inspiratory (Lower) portion
of the flow volume loop, hence variable extrathoracic UAO. The FVL shows "saw tooth sign,”
commonly reported in OSA. However, it can be seen in all cases of UAO and classically in
Parkinsonism.
21: Spirometry shows obstructive abnormality with poor bronchodilator reversibility. Good
bronchodilator reversibility criteria are an improvement of >200 ml as well as >12%,
and although there is a 21% improvement in FEV1 after bronchodilator use, the absolute
improvement is only 90 ml. Reduction in FVC is known to occur in moderate to severe airways
obstruction due to the air getting trapped; hence, as per the spirometry interpretation, this
is not a mixed defect, but a purely obstructive one.

91
 One can confidently conclude that, in this case, the low FVC is not due to a restrictive
component as, clinico-radiologically, there is no cause for restriction. The patient has chronic
airways obstruction, which could be due to asthma or COPD, as, for both these conditions,
he has predisposing factors, i.e., atopy as well as a history of substantial tobacco smoking.
Although poor bronchodilator reversibility is associated with COPD, it may also be seen in
chronic severe asthma (“fixed asthma”). The 2005 ATS/ERS Consensus Guidelines state that
when it is difficult to differentiate between BA and COPD, the patient should be treated for
BA.
22: FEV1/FVC of 63%, i.e., <70%, indicates obstructive abnormality with poor bronchodilator
reversibility (following a bronchodilator, change in FEV1 of only 20 ml and 1%). COPD severity
is of Class 2 as per the GOLD guidelines, because the FEV1 is 67%, i.e., between 60% and 80%.
Note that as per the GOLD guidelines, post-bronchodilator values are used for interpretation
of spirometry in COPD.
Here, the first-line treatment should be bronchodilator therapy, preferably LABAs like
salmeterol or formoterol, or long-acting, muscarinic receptor-antagonists (LAMAs) like
tiotropium via the inhaled route. In addition, an annual influenza vaccine must be given to
reduce episodes of acute exacerbation of COPD (AECOPD).
23: The recurrent pneumothorax is secondary to asthma. Asthma is diagnosed, based on
atopy in the patient in the form of allergic rhinitis, and spirometry shows obstructive
abnormality with good bronchodilator reversibility. As the FEV1 is 45%, the severity grade as
per the GINA guidelines is that of severe asthma. The low FVC of 55% to does not indicate
associated restrictive abnormality as there is no clinico-radiological reason to suspect
restriction (spirometry was performed 1 month after successful intercostal tube drainage of
pneumothorax).
24: Normal FEV1/FVC of 90% along with reduced FVC of 60% and FEV1 of 67% suggest a mild
restrictive abnormality. This abnormality, which is seen in early interstitial lung disease due
to reduced FVC but preserved flow rates, is evident in the FVL presenting in the form of a tall
narrow graph. There is a 300 ml improvement in FVC after OCS, indicating a good response.
NSIP type of IIP shows excellent response to corticosteroids.
25: The baseline study represents normal spirometry. Asthma therapy has been initiated due to
cough-variant asthma. Asthma is confirmed by spirometry showing marked improvement in
all parameters, (FEV1 increasing by 450 ml and 20%) after 4 weeks of treatment with ICS and
LABAs. Further, there is a fall to baseline values after omission of LABAs for 48 hours. Asthma
therapy must be continued long-term.
26: The FVL does not show upper airways obstruction, but is a miniature, normal-shaped
graph suggesting a restrictive abnormality, which is known in normal kyphoscoliosis due
to deformity in the chest wall. This is confirmed by the FEV1/FVC of 82% along with reduced
FVC of 26% and FEV1 of 25%. SDB in kyphoscoliosis is called Quasimodo’s (after the famous
hunchback of Notre Dame, in Victor Hugo’s novel) syndrome. A sleep study, therefore, would
be the next step in the evaluation of this case.

92
27: Spirometry report shows a flattening of the inspiratory (Lower) and expiratory (Upper
portions of the FVL, and hence, a fixed UAO. The Empey’s index, and the ratio of FEF50/FIF50,
confirms UAO and fixed UAO, respectively. In a case of “poorly controlled asthma”, a FVL that
shows UAO indicates vocal chords dysfunction (VCD) syndrome, which can be confirmed by
the presence of fixed, immobile vocal chords with a narrow (“chink-Like”) opening. VCD is a
conversion disorder that occurs in the background of mild to moderate asthma along with
a family history of psychiatric illness, and is seen more commonly in women and, often,
in medical/paramedical workers. Treatment consists of counselling, speech therapy, and
management of the underlying asthma.
VCD is often misdiagnosed as severe uncontrolled asthma and patients are given frequent
corticosteroid therapy and emergency/critical care management.
28: The spirometry report shows a flattening of the inspiratory (Lower) portion of the FVL, and
hence, variable extrathoracic UAO. The presence of UAO (in this case, in the supine position)
indicates surgery for goitre.
This case illustrates that the FVL must be performed in the specific position in which the
patient complains of having dyspnoea.
29: The FVL shows the “two-can filling effect” or the “biphasic graph”, suggestive of mainstem
bronchus. In this case, CXR and HRCT thorax showed right lung collapse due to obstruction
of the right main bronchus. Fibreoptic bronchoscopy showed a mass in the right main
bronchus, which, on histopathology, showed features of squamous cell carcinoma.
Using the “rule of five”, one-fifth functioning is attributed to each lobe in the lungs. Thus, for
FEV1, one-fifth of 1.38 L = 0.28 L for each lobe. As there are three lLobes in the right lung, the
total FEV1 that will be deducted after a right pneumonectomy is 0.28 L x 3 - 0.84 L. As per the
calculation of ppo FEV1, which is 1.38 L-0.84 L = 0.54 L, the patient is unfit for lung resection
surgery.
30: The FVL does not suggest UAO, but shows a restrictive pattern, i.e., a miniature loop. Normal
FEV1/FVC of 88% along with reduced FVC of 29% and FEV1 of 30% support a restrictive
abnormality. The post bronchodilator changes in FEV1 are 170 ml and 24%, which can
occur due to the normal variability between spirometric recordings and does not indicate
bronchodilator reversibility. Obesity may be associated with obstructive sleep apnoea,
wherein the FVL could be expected to show variable extrathoracic UAO. However, morbid
obesity can cause exertional dyspnoea due to a severe deconditioned state, as well as
restrictive abnormality due to poor compliance of the chest wall.
31: Although FEV1/FVC is normal (81%) in the pre-bronchodilator test good bronchodilator
reversibility i.e. improvement in FEV, 27% and 280 ml after bronchodilator is suggestive of
obstructive abnormality with a clinical correlation. The asthma is server; as indicated by
FEV, of 55% (Rule of 60-80). As reduction in FVC is known to occur in moderate to severe
airway obstruction due to air trapping, FEV1/FVC in this case shows “false normalization”.
The patient has associated gastroesophageal reflux disorder (GERD), which is confirmed
on esophageal pH monitoring. The “gold standard” study for confirming or excluding the
presence of abnormal GER is the 24-hour ambulatory esophageal pH monitoring test. Recent

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 studies also suggest that the response to a short course of empiric treatment with a high
dose of acid suppression medications (eg, 40 mg of omeprazole in the morning and 20 mg
in the evening for 7 days) is helpful in diagnosing GERD in patients with typical symptoms.
Studies have shown that 50%-90% of people with asthma also suffer from gastric reflux. In
such cases, in addition to asthma treatment anti-reflux is also necessary.
32: FEV1/FVC 37% i.e. < 70% indicates obstructive abnormality. Change in FEV, following
bronchodilator only 80ml and 1% indicates poor bronchodilator reversibility. COPD severity
is GOLD class 4 as the FEV1% is 24% (Rule of 30-50-80). Note that post bronchodilator values
are used for interpretation of spirometry for COPD and presence or absence of reversibility is
not relevant for diagnosing COPD (Global Initiative on Obstructive Lung disease-GOLD 2006).
His Dual Energy Xray Absorption (DEXA) scan shows reduced bone mineral density (BMD)
indicated by a T score of <-2.5, suggesting high risk for fragility fractures. DEXA measured
Fat Free MASS index (FFMI corrected for height squared) is 13 Kg/m2 (normal 16 Kg/m2).
Reduced FFMI is as a result of skeletal muscle loss (sarcopenia) in patients with COPD and
is called pulmonary cachexia. It is a significant independent predictor of mortality. The
systemic inflammation induced by smoking cause several co morbid conditions that must be
evaluated to assess severity of COPD in addition to spirometry. The BODE (body mass index,
obstruction, dyspnoea, and exercise tolerance) index is useful to assess the respiratory and
systemic expressions of COPD.
33: Standing height may be affected by disease, such as in kyphosis and kyphoscoliosis. One can
then substitute arm span for standing height in such cases. Arm span is measured as the
largest distance across the middle fingers when the arms are stretched horizontally sideways.
A more accurate way is to apply a small correction factor when substituting arm span for
standing height i.e. arm span / 1.03 in males and arm span/1.01 in women. However, in day
to day practice arm span may be used instead of height when height cannot be measured
easily.
34: With clinic-radiological correlation, the baseline spirometry is suggestive of a restrictive
abnormality (low FVC). In restrictive abnormalities the FEV1 is reduced in proportion to
FVC, maintaining a normal FEV1/FVC ratio. After bronchodilators the change in FEV1 from
baseline test is 16% and 180 ml, which would be read as poor bronchodilator reversibility.
Following 4 weeks of oral corticosteroids there is improvement in FVC by 14%. In interstitial
lung diseases criteria for objective improvement post therapy is improvement in FVC by
10% (or improvement in DLCO by 15%). The second spirometry in this case now shows good
bronchodilator reversibility i.e. improvement in FEV1 by 220 ml and 17%. Airway obstruction
is reported in 5-60% of pulmonary sarcoidosis cases and may result from the compressive
enlarged lymph node, airway distortion attributable to pulmonary fibrosis or narrowing
of the bronchial wall due to granulomatous lesions. The latter may cause bronchial hyper-
reactivity and may get symptom relief with inhaled and oral bronchodilators and inhaled
steroids.
35: The first study (2000) shows obstructive abnormality with good bronchodilator reversibility.
Spirometry suggests asthma is severe (FEV1<60%). The second study (2008) also shows
obstructive abnormality with good bronchodilator reversibility. Although the FVC is higher,

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 there is a fall FEV1 by 230ml. This could have been considered as normal decline in FEV1
(30-50 ml/year X 7 years). However, as the FVC is heigher by 260 ml the low FEV1 indicates
worsening asthma. The bronchodilator reversibility signifies that the lung functions can be
restored to normal even now if optimum treatment is given. This is unlike COPD where
progressive and irreversible loss of lung functions occur over a period of time and smoking
cessation can arrest the decline but cannot restore lung functions to normal.
36: The pre treatment spirometry shows obstructive abnormality (FEV1/FVC 60%) with good
bronchodilator reversibility, improvement in FEV1 by 33% and 550ml. Asthma severity is
‘’severe asthma’’ based on FEV1 47% i.e. <60% (Rule of 60-80). Following 2 weeks of treatment
the spirometry is normal, FEV1/FVC 88% and there is change in FEV1 following bronchodilator
administration. Samter’s triad consists of asthma, nasal polyposis and aspirin sensitivity. It is
also known as aspirin-sensitive asthma, aspirin triad, Widal’s triad: aspirin induced asthma
and rhinitis (AIAR) and aspirin-exacerbated respiratory disease (AERD). The onset of symptoms
is more commonly in the twenties and thirties. Some patients require initial oral steroids to
alleviate asthma and nasal congestion. The preferred treatment is desensitization to aspirin.
Patients who are desensitized need maintenance dose of aspirin daily to control symptoms
asthma and sinusitis. Additionally they may continue to use nasal steroids, inhaled steroids,
and bronchodilators. Leukotriene antagonists have also shown benefit. Occasionally surgery
may be required to remove polyps but they are likely to recur without desensitization.
37: The initial spirometry shows obstructive abnormality (FEV1/FVC 57%) with poor bronchodilator
reversibility, improvement in FEV1 by 3% and 20ml. The second spirometry following a
course of oral corticosteroids shows obstructive abnormality (FEV1/FVC 59%) with poor
bronchodilator reversibility, improvement in FEV1 by 12% and 120ml. However, the post
steroid improvement in FEV1 is significant i.e. 38% and 290ml.
In cases where diagnosis asthma is difficult, a steroid trial i.e. appropriate doses of inhaled
steroids for 4-6 weeks or oral steroids for 10-14 days (adult) resulting in >20% improvement
in FEV1 may be used to confirm asthma.
38: The spirometry shows obstructive abnormality (FEV1/FVC 60% in pre-bronchodilator and 70%
in the post-bronchodilator test) with good bronchodilator reversibility, improvement in FEV1
by 33% and 550ml. Spirometry criteria for diagnosis of COPD is traditionally irreversible
airway obstruction and significant reversible airway obstruction is considered to be the
diagnostic criteria for asthma. Global initiative on Obstructive Lung Diseases (GOLD) guidelines
2006 update has recommended that demonstration of ‘’irreversible airway obstruction’’
i.e. absence of bronchodilator reversibility is no more required for diagnosis of COPD. The
severity of COPD based on spirometry (rule of 30-50-80) in this case is moderate COPD (post
bronchodilator FEV1 62% predicted). Note that in case of COPD post bronchodilator values
are used for interpretation and severity assessment (GOLD guidelines).
39: Spirometry shows normal lung functions, no obstructive abnormality as the FEV1/FVC is
83.77% (>70%) and no restrictive abnormality as the FVC is 83% predicted (>80%). The MMFR
or forced expiratory flow (FEF) 25-75% is the maximal mid expiratory flow rate i.e. the maximal
flow between 25-75% of the expiration. It was considered to be an important parameter
to diagnose small airway obstruction. One of the criteria for acceptable spirometry test is

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 duration of expiration of 6 seconds (FEV6) or a 2 second plateau. COPD patients can expire
for longer than 6 seconds. As a result the mid expiration changes significantly depending on
the duration of expiration resulting in marked variability of MMFR between tests. MMFR is
therefore no more used as an indicator of small airway obstruction. Lung age (LAGE) is the
chronological age at which observed spirometric values would have been recorded (based
on the predicted values), if the individual had no lung disease.
40: FEV1/FVC is 83% and FVC is 70% predicted, hence normal spirometry. In addition lung
volumes and capacities and airway resistance (Raw) are also normal. This individual
is a ‘’non susceptible smoker’’. The dominant, confirmed cause behind COPD is tobacco
smoking. However, only 15-50% of individuals who smoke develop COPD, and these are
called ‘’susceptible’’ individuals. Polymorphism for the genes controlling oxidant-antioxidant
balance may explain this susceptibility. Cigarette (or beedi) smoking is measured in pack-
years (cigarettes a day x years smoking / 20) or smoking index (cigarette a day x years
smoking). Although some recommend >20 pack-years (smoking index = 400) for diagnosis of
COPD, pulmonary symptoms are likely to occur in susceptible individuals once 10-pack-years
(smoking index = 200) history is reached. Hence, individuals with a 10-pack-years history
and who have symptoms should be screened for COPD.

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