PULMONARY FUNCTION TESTS

MODERATOR:DR SHRAVYA
PRESENTOR:DR RANI
 CONTENTS
1. Introduction to PFTs
2. Lung Volumes and Capacities
3. Categorization of PFT’s
4. Bedside pulmonary function tests
5. Static lung volumes and capacities measurement
6. Measurement of FRC, RV
7. Dynamic lung volumes/forced spirometry
8. Flow volume loops and detection of airway
obstruction
9. Flow volume loop and lung diseases
10. Assessment of gas exchange function
11. Assessment of cardiopulmonary reserve
12. Preoperative pulmonary assessment
 Introduction
• PFT is a term used to indicate a battery of tests/ maneuvers that
may be performed using standardized equipment to measure lung
function
• Includes wide variety of objective tests to identify and quantify
lung function
• Only supports or excludes a diagnosis
• Evaluate one or more major aspects of the respiratory system:
1. Respiratory mechanics
2. Lung parenchyma function
3. Cardiopulmonary interaction
 Indications
Diagnostic Prognostic
 Evaluation of signs &  Assess severity of pulmonary
symptoms ‐ chronic cough, disease (eg COPD, ILD,
exertional dyspnea Asthma etc)
 Screening at risk patients  Follow response to therapy

 To assess preoperative risk  Determine further treatment

goals
 Monitor pulmonary drug
toxicity  Evaluating degree of
disability
 Tisi guidelines
 Age > 70
 Obese patients
 Thoracic surgery
 Upper abdominal surgery
 History of cough/ smoking
 Any pulmonary disease
 American College of Physicians
Guidelines
 Lung resection
 H/o smoking, dyspnoea
 Cardiac surgery
 Upper abdominal surgery
 Lower abdominal surgery
 Uncharacterized pulmonary disease(defined as history of
pulmonary Disease or symptoms and no PFT in last 60
days)
 Contraindications
• Myocardial infarction within the last month
• Unstable angina
• Recent thoraco-abdominal surgery
• Recent ophthalmic surgery
• Thoracic or abdominal aneurysm
• Current pneumothorax
 Limitations

1. Variability in normal predictive value

2. Accuracy- Technician’s skill & patient’s understanding &
cooperation
3. Must be combined with proper history, physical examination,
ancillary diagnostic tests to confirm diagnosis
 PFT Categories

Ventilatory
Gas Exchange Cardiopulmonary
functions of lung
tests interaction
/ chest wall
 OTHER TEST
• Test to detect airway obstruction
include airway resistance ,FRV1/FVC and Flow
volume loop curves
 Ventilatory functions of lung / chest
wall
• Bed side pulmonary function tests
• Static lung volumes & capacities ( VC, IRV, ERV, RV,
FRC)
• Dynamic lung volumes ( FVC, FEV1, FEF 25-75%,
PEFR, MV, Resp muscle strength)
 Gas exchange tests

• Alveolar-arterial pO2 gradient

• Diffusion capacity
• Gas distribution tests -
1) Single breath N2 test.
2) Multiple Breath N2 test
3) Helium dilution method
4) Radio Xe scinitigram
 Cardiopulmonary interaction

 Qualitative tests
– History & examination
– ABG

 Quantitative tests
– 6 min walk test
– Stair climbing test
– Shuttle walk
– CPET(cardiopulmonary exercise testing)
 Ventilatory functions of lung / chest
wall
• Bed side pulmonary function tests
• Static lung volumes & capacities ( VC, IRV, ERV, RV,
FRC)
• Dynamic lung volumes ( FVC, FEV1, FEF 25-75%,
PEFR, MV, Resp muscle strength)
 LUNG VOLUMES & CAPACITIES
Volumes Capacities
Tidal volume Inspiratory capacity
Inspiratory reserve volume Expiratory capacity
Expiratory reserve volume Vital capacity
Residual volume Functional residual capacity
Closing volume Total lung capacity
Closing capacity
STATIC LUNG VOLUMES AND
CAPACITIES
 Static lung volumes
• TV(Tidal volume)
• IRV(Inspiratory reserve volume)
• ERV(Expiratory reserve volume)
• RV(Residual volume)
• VC(Vital capacity)
• IC(Inspiratory capacity)
• TLC(Total lung capacity)
• FRC(Functional residual capacity)
TIDAL VOLUME
o Volume of air inhaled or exhaled
with each breath during quite
breathing.
o 6-8 ml/kg
o TV decreases with decrease in
compliance

INSPIRATORY RESERVE
VOLUME
o Maximum volume of air that can
be inhaled from the end
inspiratory tidal position.
o 1900-3300 ml

EXPIRATORY RESERVE
VOLUME

o Maximum volume of air that can

be exhaled from resting end
expiratory tidal position.
RESIDUAL VOLUME

o Volume of air
remaining in lungs
after maximum
exhalation
o 20-25 ml/kg (1100-
1200 ml)
o Cannot be measured by
spirometry
o Measured indirectly
(FRC-ERV)
TOTAL LUNG CAPACITY
o Sum of all volume compartments
o Volume of air in lungs after maximum
inspiration
o 80-100ml/kg (4-6 L)

VITAL CAPACITY
o TLC-RV
o Maximum volume of air exhaled from
maximal inspiratory level.
o 60-70 ml/kg (5L)

INSPIRATORY CAPACITY

o IRV+TV
o Maximum volume of air that can be
inhaled from the end-expiratory tidal
position
o 2400-3800ml

EXPIRATORY CAPACITY

o TV+ ERV
 Factors affecting vital capacity
• Altered muscle power:Neurological or muscular diseases
• Pulmonary diseases:COPD,Asthma,pulmonary fibrosis
• Lesions affecting chest wall
movements:kyphoscoliosis,tumors of chest wall,pleural
effusion
• Abdominal masses which affect descend of diaphragm
• Abdominal or thoracic surgeries
• position:lithotomy decreases by 18% and trendelenberg
decreases by 14%(because in these positions diaphragm is
pushed upwards)
• Tight abdominal splinting
RESTRICTIVE LUNG DISEASE OBLUNG DISEASESTRUCTIVE

All lung volumes reduced Initial phase:RV increased and all

other volumes decreased .TLC
normal (airtrapping)

Tidal volume may be normal or Late phase:marked increase in RV

reduced and TLC

Pleural fibrosis,pleural effusion COPD,asthma

 Functional Residual Capacity (FRC)
 Sum of RV and ERV or the
volume of air in the lungs
at end-expiratory tidal
position.
 (30-35 ml/kg) ;2500 ml
 Under GA; FRC decreases
by 16-20%
Decreases in: Increases with:
 Obese patients  Increased height

 Supine position (0.5-  Erect position (30% more

1 L) than in supine)
 Induction of  Decreased lung recoil
anaesthesia- dec. by (emphysema)
16-20%
 RLD (fibrosis,
pregnancy)
 FRC and its Anaesthetic Importance
• Anesthesia decreases FRC BY 16-20%
• Mechanism: anesthesia relaxes diaphragm
and intercostal muscles and the chest wall
shape changes
• So decreases FRC leads to atelectasis which
further leads to hypoxia and postoperative
pulmonary complications
 FRC AND OBESITY
• obesity decreases FRC BY 16-20%

• Mechanism:the adipose tissue and abdominal

fat content causes splinting of diaphragm and
chest wall limiting excursion
 Importance of FRC
• When FRC is less than closing capacity,airways
close in the dependent parts of the lung
during certain periods of normal tidal
ventilation
• blood oxygenation during the expiratoey
phase is mainly dependent on the remaing
lung volume,which is FRC
 SPIROMETRY
• Cornerstone of all the pulmonary function tests
• Spirometry is a medical test that measures the volume
of air an individual inhales or exhales as a function of
time.
• Assess mechanical function of lungs
• Measures amount and rapidity of air that can be
exhaled or inhaled by the person
• Primary signal measured may be volume or flow
• CAN’T MEASURE – FRC, RV, TLC
Types of spirometer
 Bellows or rolling seal
• large and used in lung function labs
• Measure volume
 Electronic desktype
• Portable ,quick and easy to use .Real time
visual display
• Measure flow and volume
 Hand-held spirometers

• Inexpensive and quick to use but no print out

Volume measuring spirometer
Flow measuring spirometer
Desktop electronic spirometer
Small hand held spirometer
 Prerequisites
• No smoking 1hour prior to testing
• No alcohol 4hour prior testing
• No vigorous excercises 30min prior testing
• Avoid wearing tight clothes during testing
• Avoid testing after heavy meals
 Withholding medications before
performing spirometry
• Short acting beta 2 agonist for 6hours
(terbutaline,salbutamol)
• long beta 2 agonist for 12hours (salmetrol and
formoterol)
• Ipratropium for 6hours
• Tiotropium for 24hurs
 What constitutes normal spirometry?
 Normal values vary and depend on:
1. Height – Directly proportional
2. Age – Inversely proportional
3. Gender
4. Ethnicity
 Procedure

• Patient in sitting or standing

position
• Place clip on nose
• Have patient breathe on
mouthpiece
• Ask patient take a deep breath as
fast as possible
• Blow out as hard as they can until
you tell them to stop
 NORMAL CURVE:
• Graphs obtained from spirometry are known as
spirograms.
• Two types :
• Volume – time curve
• Flow –Volume loops
 Volume time curve
• 83% in 1st second of
their FVC
• 94% by 2 second
• 97% BY 3 second
NORMAL SPIROMETRY CURVES
 ACCEPTABILITY CRITERIA
• Effort should be maximal,smooth
• Artifacts: No coughing / glottic closure
• Exhalation time should be atleast 6 seconds
• End of the test is indicated by a 2 second volume plateau
• 3 tests of acceptable effort
COMMON ERRORS IN
SPIROMETRY
SUB MAXIMAL INHALATION
SUB-MAXIMAL BLAST
COUGH
VARIABLE EFFORT
GLOTTIC CLOSURE OR BREATH
HOLDING
 LEAK
.
EXTRA BREATH(s)
 OBSTRUCTIVE LUNG DISEASE
• FVC normal or
decreased
• FEV1 decreased
• FEF25-75% decreased
• FEV1/FVC decreased
• TLC normal or increased
 RESTRICTIVE LUNG DISEASE
• FVC decreased
• FEV1 decreased
• FEF25-75% normal or
decreased
• FEV1/FVC normal
increased
• TLC normal or
decreased
 Measurement of RV, FRC

Methods:
 Nitrogen washout technique
 Helium dilution method
 Body plethysmography
 Nitrogen washout technique
100% oxygenation

All nitrogen in lungs washed out

Exhaled volume and the nitrogen

concentration in that volume are
measured.
 Helium Dilution technique
Pt breathes in and out from a reservoir with known
volume of gas containing trace of helium.

Helium gets diluted by gas previously present in

lungs.

• C1×V1 = C2×V2
• C1×V1 = C2×(V1+FRC)
• FRC = ((C1xV1)/C2) - V1

• V2 = total gas volume ( FRC + volume of

spirometer)
• V1 = volume of gas in spirometer
• C1 = initial (known) helium concentration
• C2 = final helium concentration (measured by
the spirometer)
 BODY PLETHYSMOGRAPHY
• Also known as body box
• Patient sits in airtightchamber
• Uses boyles law:Pressure and volume vary inversely if
temperature is constant
• Measures all the gas within the chest
• When patient is box,two volumes of gas being considered
• Volume within the lungs(unknown) and volume within
the box(known)
• Volume in box=original volume-volume patient occupies
 BODY PLETHYSMOGRAPHY
• Based on Boyle’s law.
P x V = Constant

• Gas volume in lung=

Body box gas volume Gas pressure in the box
Gas pressure in the lung
 BODY PLETHYSMOGRAPHY
As measurements done at end of expiration, it
yields FRC
Body plethysmography is the gold standard
for measurement of lung volumes, particularly
in the setting of significant airflow obstruction
 Helium dilution and nitrogen washout may
underestimate lung volume in patients with
moderate to severe COPD because they do
not access under or nonventilated areas
.
 Dynamic lung volumes/forced
Spirometry
• FVC
• FEV1
• FEF:FEF 25%,FEF50%,FEF75%,FEF25-
75%,FEF200-1200%
• MBC
 Forced spirometry or Time expiratory
spirogram
• After a maximal
inspiration
• Expires forcefully and
maximally into a
spirometer
• Atleast 4 second
exhalation
• Amount of air expelled
over each second
calculated
• Expressed as % of FVC
 FORCED VITAL CAPACITY
• Maximum volume of gas that can be exhaled
as forcefully and rapidly as possible after a
maximl inspiration
 FEV1
• Forced expiration volume at the end of
1second
• Maximum volume of gas which can be forcibly
exhaled during fisrt second of forced
expiratory volume
• Flow rate per second
• Patients with large airway obstruction will
have reduced FEV1
 FEV1
• Normal adult:3-4.5L
• Mild to moderate obstruction:1.5-2.5L
• Severe obstruction:<1L
 FEV1/FVC
• Percentage of total Forced vital capacity
during first second of forced exhalation
• More sensitive than FEV1 alone
• Falls linearly with progression of obstructive
lung disease
 FEV1/FVC
• >75% Normal
• 60%-75% Mild obstruction
• 50-59% Moderate
obstruction
• <49% Severe
obstruction
 FEF(FORCED EXPIRATORY FLOW)
• Divided into quartiles:FEF25%,50%,75%
• Reduced in large airway obstruction
 Forced mid-expiratory flow 25-75%
• Max. Flow rate during the mid-
expiratory part of FVC maneuver.
• Measured in L/sec
• May reflect effort independent
expiration and the status of the small
to medium airways
• Highly variable
• Depends heavily on FVC
• N value – 4.5-5 L/sec or 300 L/min.
Forced mid-expiratory flow 25-75%
• >60% Normal
• 40-60% Mild obstruction
• 20-40% Moderate
obstruction
• <10% Severe obstuction
 PEAK EXPIRATORY FLOW RATE
• Maximum flow rate during an FVC maneuver
• After a maximal inspiration, the patient expires as
forcefully and quickly as he can and the maximum flow
rate of air is measured
• Gives a crude estimate of lung function, reflecting
larger airway function
• Effort dependent but is highly reproducible
FEV1 Large upper airway Very effort
dependent
FEV2 AND FEF25- Small bronchi and Less effort
75% larger bronchioles dependent
FEV3 AND FEF75- SMALLER Effort independent
85% BRONCHILOES
• Measured by peak flow meter

• How much air (L/min) is being

blown out or by spirometry
• In normal adults variation depends on
age and height.
• Normal :
Males: 450 - 700 L/min
Females: 300-500 L/min
• Decreased in airway obstruction and
muscle weakness
• Clinical significance - value of
<200L/min- impaired coughing &
hence likelihood of post-op
complication
Maximum Voluntary Ventilation (MVV)

• Also known as Maximum Breathing Capacity (MBC)

• Measures - speed and efficiency of filling & emptying of
the lungs during increased respiratory effort
• Maximum volume of air that can be breathed in and out
of the lungs in 1 minute by maximum voluntary effort
• It reflects peak ventilation in physiological demands
• Normal : 150 -175 L/min.
• Decreased in obstructive disorders
• <80% - gross impairment
• MVV=FEV1 35
• Patient breaths as
quickly and deeply
as possible for 12
sec and the
measured volume is
extrapolated to1min.
Maximum Voluntary Ventilation (MVV)

Affected by
• The elastic properties of lung
• Chest wall fuction
• Respiratory muscle strength
 MVV is decreased in patients with:

• Emphysema
• Airway obstruction
• Poor respiratory muscle strength
 BED SIDE PFT
1. Sabrasez breath holding test
2. Single breath count
3. Schneider’s match blowing test
4. Cough test
5. Forced expiratory time
6. Wright peak flowmeter
7. Microspirometers
8. Debono whistle blowing test
9. Wright respirometer
10. Bed side pulse oximetry
11. Watch and stethoscope test
12. Chest expansion
SABRASEZ BREATH HOLDING TEST:

Ask the patient to take a full but not too deep

breath & hold it as long as possible.

 >25 SEC-NORMAL Cardiopulmonary Reserve (CPR)

 15-25 SEC- LIMITED CPR
 <15 SEC- VERY POOR CPR

 25- 30 SEC - 3500 ml VC

 20-25 SEC - 3000 ml VC
 15-20 SEC - 2500 ml VC
 10-15 SEC - 2000 ml VC
 5-10 SEC - 1500 ml VC
SCHNEIDER’S MATCH BLOWING TEST

 Measures Maximum Breathing Capacity

 Ask to blow a match stick from a distance of 6” (15 cm)
with-

 Mouth wide open

 Chin rested/supported

 No purse liping
 No head movement
 No air movement in the room
 Mouth and match at the same
level
 Cannot blow out a match
 FEV1 < 1.6L

 Ableto blow out a match

 FEV1 > 1.6L

 Modified
match test:
 DISTANCE MBC (Max Breathing Capacity)
 9” >150 L/MIN
 6” >60 L/MIN
 3” > 40 L/MIN
 COUGH TEST
Deep breath followed by cough
 Ability to cough
 Strength
 Effectiveness of action of respiratory. muscles
Inadequate cough if:
 FVC <20 ml/kg
 FEV1 < 15 ml/kg
 PEFR < 200 lit/min.

 VC ~ 3 times TV for effective cough

 A wet productive cough / self propagated paroxysms of coughing
may indicate some underlying pathology – susceptibility for
pulmonary complication.
FORCED EXPIRATORY TIME:
 After deep breath, exhale maximally and forcefully & keep
stethoscope over trachea & listen
 Normal FET – 3-5 sec
 OBS. Lung Disease > 6 sec
 RES. Lung Disease < 3 sec

SINGLE BREATH COUNT:

 After deep breath, hold it and start counting till the next breath
 Normal- 30-40 count
 Indicates vital capacity
 DE-BONO WHISTLE BLOWING TEST
Measures PEFR

Patient blows down a wide bore tube

at the end of which is a whistle, on
the side is a hole with adjustable
knob
As subject blows → whistle blows,
leak hole is gradually increased till
the intensity of whistle disappears
At the last position at which the
whistle can be blown , the PEFR can
be read off the scale
 WRIGHT RESPIROMETER

Measures TV & MV
 Instrument- compact, light and
portable
 Can be connected to endotracheal
tube or face mask
 MV- instrument record for 1 min.
And read directly
 TV-calculated and dividing MV by
counting Respiratory Rate.
 Disadvantage: It under- reads at
low flow rates and over- reads at
high flow rates
 Minute ventilation
• It is the amount of air moved in or out of the
lungs per minute
• Minute ventilation(ml/min)
=tidal volume(ml) Respiratory rate(bpm)
• Minute ventilation increases with exercise as
both tidal volume and respiratory rate
increases
WRIGHT PEAK FLOW METER:

Measures peak expiratory flow

rate

 Male: 450-700 L/min.

 Female: 350-500 L/min.
 MICROSPIROMETER

 Measure FEV1, FVC

 Chest expansion
• Measure the chest circumference during quit
inspiration and expiration at the level of nipple
• Normal:4-5 cm in adult
• Altered in:
o muscle disease
o Chest injury
o Lung disease of any organ
Flow-Volume loops and their interpretation
 Flow-Volume loops
• Provides graphic analysis of flow at various lung volumes.
• Augments spirometry results.
• Principal advantage of flow volume loops vs. typical standard
spirometric descriptions - identifies the probable obstructive
flow anatomical location.

.
 PROCEDURE
• Patient inhales fully to Total lung capacity(Volume
of air in lungs after maximum inspiration)
• Then perform FVC maneuver(Maximum volume
of gas that can be exhaled as forcefully and rapidly
as possible after a maximl inspiration)
• Followed by maximum inspiration
• X axis:volume
• Y axis: flow
 Flow-Volume loops
• First 1/3rd of expiratory flow is effort dependent and the final
2/3rd near the RV is effort independent.
• Inspiratory curve is entirely effort dependent.
• Differentiate between upper and lower airway obstruction.
• It measures:
• a)Maximal flow rate during expiration (i.e.PEFR).
• b)FEF 25-75% - tells about small airway function.
 Flow-Volume loops
• Shape of the flow volume loop depends on:
• Behaviour of lesion:
 Variable.
 Fixed.
• Location of lesion:
 Extrathoracic.
 Intrathoracic.
Flow volume loops and detection of airway
obstruction:
Normal curve
• Up is expiratory portion
• Down is inspiratory
portion
 Variable Extrathoracic airway obstruction

• Inspiratory part is
affected

1.Bilateral and unilateral

vocal cord paralysis
2. Vocal cord constriction
3. Chronic neuromuscular
disorders
4. Airway burns
5. OSA
 Reason
• A variable extra thoracic obstruction increases
the turbulence of inspiratory flow, and During
inspiration,the pressure in the trachea
becomes negative relative to atmospheric
pressure.this leads to partial collapse of an
already narrowed airway
 Variable Intrathoracic airway
obstruction:expiratory part is affected

1.Tracheomalacia
2. Polychondritis
3. Tumors of trachea or main
bronchus
 reason
• Because intrapleural pressure becomes
markedly positive during forced expiration and
causes dynamic compression of the
intrathoracic airways
• The obstruction caused by an intrathoracic
lesion is accentuates and a plateau in
expiratory flow occurs on the flow volume
loop
 Fixed Obstruction

Constant airflow limitation

during inspiration and
expiration.
• Benign stricture
• Goiter
• Endotracheal neoplasms
• Bronchial stenosis
• Tracheal stenosis
 Obstructive lung disease
• There is expiratory flow limitation
• So there is dip in the expiratory portion of the
loop
 Obstructive lung disease
A) Asthma

• Flow rate is decreased due .

to intrinsic narrowing of
airways caused by
contraction ofsmooth
muscles and inflammatory
changes.
• PEFR is decreased.
• Concavity- Indicator of
airflow obstruction and may
present before the change in
FEV1 or FEV1/FVC
 B) Emphysema
• The loss of elastic recoil
and radial support because
of destruction of supporting
lung tissue results in
pressure dependent
collapse of the distal
airways with more
pronounced“scalloping” of
the expiratory limb.
• Also known as “dog leg
appearance” or “coving”.
• PEFR can be mildly to
severely reduced.
Reversibility-Bronchodilator testing
• The diagnostic hallmark of asthma is the presence of reversible
airways obstruction.
• Any change in the airway indices following the administration of a
bronchodilator such as is noted.
• A positive response in adults is defined as Improvement in FEV1
by 12-15% or 200 ml in repeati ng spirometry aft er
treatment with Salbutamol 2.5mg or ipratropium bromide
by nebulizer aft er 15-30 minutes.

• In chronic asthma there may be only parti al reversibility

of the airfl ow obstructi on
• While in COPD the airfl ow is irreversible although some
cases showed signifi cant improvement
 Restictive lung disease
• Flow rates are preserved
but the problem relates to a
parenchymal disorder e.g.
lung fibrosis which reduces
lung volumes.
• Peak expiratory flow may be
preserved or even higher
than predicted leads to tall,
narrow and steep flow
volume loop in expiratory
phase.
• Shape will be same but size
is reduced
Interpretation of PFT
 Assessment of gas-exchange function:

Test to assess gas exchange

• Diffusion capacity(DLCO)
• Alveolar-arterial oxygen tension gradient
 Diffusing Capacity
• It is the ability of a gas to
move across the alveolar-
capillary membrane.
• Normal- 20-30 ml/min/mm
Hg
 DIFFUSION DEPENDS ON
• Diffusion coefficient of the gas used in testing
• Surface area of the membrane
• Thickness of the membrane
• Hemoglobin
 PROCEDURE
• Patient breaths room air several breaths
• Exhales completely
• Then patient breaths rapidly and deeply:0.3%
Carbon monoxide,10%helium,21% O2 AND
remaing nitrogen
• Holds breath for 10second
• Calculate rate of blood uptake by difference of
inspired and expired concentration of Carbon
monoxide
 DLCO(diffusion capacity of the lungs for carbon monoxide)

• Carbon monoxide is used because of its high affinity for

haemoglobin. This maintains low partial pressures in the
blood so its uptake is primarily determined by diffusion across
the alveoli.
 DLCO is reduced by:
• Impaired diffusion - i.e. increased thickness (lung fibrosis).
• Decreased area (lung resection, emphysema).
• Reduction in the ability to combine with blood (e.g. anaemia).
 DLCO is increased by:
• Polycythemia
• Asthma
• Pulmonary hemorrhage
• Congestive heart failure
Alveolar-arterial oxygen tension gradient
CLOSING VOLUME

It is the lung volume

below which small airways
begin to close or cease to
contribute expiratory gas.

CLOSING CAPACITY

CC = CV + RV
 CLOSING VOLUME
• Single breath N2 wash out test
• Patient inhales a single breath of 100% oxygen
and slowly exhales while level of N2 is
measured
 Flowers method of single breath nitrogen
washout test
• Phase 1:since the patient
has taken 100% oxygen ,so
phase 1 will be 1005 oxygen
• Phase 2:mixture of dead
space and alveolar gas
• Phase 3 :plateau produced
by exhalation of alveolar gas
• Phase 4:abrupt increase in
% of N2, Which continues
until RV
 6-minute Walk Test

• Expressed interms of V02 MAX .

• VO2 max= maximum capacity of an individual’s body to
transport and use oxygen during incremental exercise
• It is ml/kg/min: mililitres of oxygen per kg of body
weight per minute
• Walk 180feet in 1min or 6min walk test of: 1080feet-
V02 max of 12ml/kg/min
>2000feet-VO2MAX of >15ml/kg/min
• 4% SpO2 fall indicate poor pulmonary reserve
 RESPIRATORY MUSCLE STRENGTH
ASSESED BY
• Maximum inspiratory pressure
• Maximum expiratory pressure
 Maximum inspiratory pressure

• Normal value:-50 to -100cm of H20

• Less than -20 cm of H20 indicates need for
mechanical ventilation
• Minimum of -20cm of H2O is required for
successful weaning
 INDICATIONS
• Weaning parameter
• Monitor neuromuscular disease
• To determine need for mechanical ventilation
 Maximum expiratory pressure

• Normal 90 to 100 cm of H2O

• <40 cm of H2O :unable to clear secretions and
maintain spontaneous ventilation,making
mechanical ventilation necessary
• Indications same as Maximum inspiratory
pressure
Assessment of cardiopulmonary reserve
Cardiopulmonary exercise testing(CPET)
• Measures three ventilatory variables:
Oxygen consumption
Carbondioxide secretion
Minute ventilation
• VO2 = C.O* [ CaO2 – CvO2 ]
• Normally VO2= 250 ml/min
• VO2 peak=highest oxygen consumption achieved during any
particular CPET.
 Procedure
• OPD basis procedure.
• To test ability of subjects physiological response to cope with
metabolic demands
• Patient sits on bicycle ergometer or walks on a treadmill and
is connected to 12 lead ECG,BP cuff and pulse oximeter.
• Inspired and expired gases are sampled.
• Gradually resistance or speed increases.
• Takes about 13 minutes.
 VO2 max and interpretation
VO2 MAX INTERPRETATION

20 ml/kg/min or >15 ml/kg/min and No increased risk of complication or

FEV1>40% predicted death

<15 ml/kg/min High risk

<10 ml/kg/min Very high risk,40-50% mortality, consider

non-surgical management
 Shuttle walk test

• The patient walks between 2 markers 10 meters apart with

increasing pace.
• The subject walks until they cannot make it from cone to
cone between the beeps
• Less than 250m= VO2 max < 10 ml/kg/min= high risk
• A shuttle walk of 350 m = VO2 max of 11 ml/kg/min.
 Exercise oximetry
• Decrease of blood oxygen saturation greater than 4% during
exercise= high risk.
Pre-operative pulmonary evaluation
 GOALS of pre operative PFT
• For whom the risk of surgery is prohibitive
• To identify patient at increase risk of
pulmnonary complication for whom better
decisions for improved pre and postoperative
care can be made
 INDICATIONS
• >60-65yrs
• Known pulmonary disease
• Pathologically obese
• h/o smoking/wheeze
• Posted for prolonged surgery
• Posted for abdominal/thoracic surgery
 DONE IN 3 PHASES
• Phase1
• Phase2
• Phase3
 Phase 1
• Evaluates total lung function
• Includes ABG and Spirometry
• Increased is present if there is:
o Hypercapnia (PaCO2 > 45mmhg) at room air
o FEV1 <2L
o FEV1 OR MBC <50% of predicted
o RV/TLC > 50%
o FEV1/FVC <50%
• In these situations,proceed to next phase
 Phase 2
• Split lung function test
• Maximum ventilation and perfusion of each
lung is measured separately by Xe or Tc
scanning
• Combining conventional Spirometry and
functional analysis
• If predicted postoperative FEV1 <0.8l
• If > 70% blood flow is to the dissected lung
• Proceed to next phase
 Phase 3
• Post operative condition of the patient is simulated by
functional resecting the vascular bed of one lung by temporary
occlusion of major pulmonary artery
• Alternative method:Block a lung by a ballon catheter through a
fibreoptic bronchoscope and measure spirometry of remaining
lung tissue and simulate post operative ventilatory function
• Supplemental oxygen must be given as the blocked segment is
still perfused
• If mean pulmonary artery pressure rises to >40mm or increase
in PaCO2 >60 and decreased PaO2 <45
• Indicates inability to tolerate removal of the lung
Milledge and Nun criteria for preoperative
assessment
• FEV1 is a useful preoperative screening test
• IF FEV1 <1L,ABG should be done
 FEV1 PaCO2 PaO2

Group 1 <1L Normal Normal Noraml post

operative
course

Group 2 <1L Normal <60 Requires O2

therapy
postoperatively

Group 3 <1l >45 decreased Requirs

postoperative
ventilation
THANK YOU