PULMONARY FUNCTION TESTS

INTRODUCTION

• Pulmonary function tests is a generic term used to

indicate a battery of studies or maneuvers that may
be performed using standardized equipment to
measure lung function.
Evaluates one or more aspects of the respiratory
system
– Respiratory mechanics
– Lung parenchymal function/ Gas exchange
– Cardiopulmonary interaction
 INDICATIONS

DIAGNOSTIC PROGNOSTIC
Evaluation of signs & symptoms‐ Assess severity
BLN, chronic cough, exertional
dyspnea
Screening at risk pts Follow response to therapy
Measure the effect of Ds on Determine further treatment goals
pulmonary function
To assess preoperative risk Evaluating degree of disability
Monitor pulmonary drug toxicity
 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
• Recent eye surgery
• Thoracic , abdominal and cerebral aneurysms
• Active hemoptysis
• Pneumothorax
• Unstable angina/ recent MI within 1 month
 INDEX

1. Categorization of PFT’s
2. Bedside pulmonary function tests
3. Static lung volumes and capacities
4. Measurement of FRC, RV
5. Dynamic lung volumes/forced spirometry
6. Physiological determinant of spirometry
7. Flow volume loops and detection of airway obstruction
8. Flow volume loop and lung diseases
9. Tests of gas exchange function
10. Tests for cardiopulmonary reserve
11. Preoperative assessment of thoracotomy patients
 CATEGORIZATION OF PFT

MECHANICAL VENTILATORY
FUNCTIONS OF LUNG / CHEST WALL:

• BED SIDE PULMONARY FUNCTION TESTS

• STATIC LUNG VOLUMES & CAPACITIES – VC, IC, IRV,
ERV, RV, FRC.
• DYNAMIC LUNG VOLUMES –FVC, FEV1, FEF 25‐75%,
PEFR, MVV, RESP. MUSCLE STRENGTH
GAS‐ EXCHANGE TESTS :

• A)Alveolar‐arterial po2 gradient

• B) Diffusion capacity
• C) 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:
1) History , examination
2) ABG
• Quantitative tests
1) 6 min walk test
2) Stair climbing test
3)Shuttle walk
4) CPET(cardiopulmonary exercise testing)
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 Bed side pulmonary function tests

RESPIRATORY RATE

‐ Essential yet frequently undervalued

component of PFT
‐ Imp evaluator in weaning & extubation
protocols

Increase RR ‐ muscle fatigue ‐ work load ‐ weaning fails

 Bed side pulmonary function tests

1) 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 (Contraindication for
elective surgery)
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
‐
 Bed side pulmonary function tests

2) SCHNEIDER’S MATCH BLOWING TEST: MEASURES Maximum

Breathing Capacity.
Ask to blow a match stick from a distance of 6” (15 cms)
with‐
 Mouth wide open
 Chin rested/supported
 No purse lipping
 No head movement
 No air movement in the room
 Mouth and match at the same level
 Bed side pulmonary function tests

• Can not blow out a match

– MBC < 60 L/min
– FEV1 < 1.6L
• Able to blow out a match
– MBC > 60 L/min
– FEV1 > 1.6L
• MODIFIED MATCH TEST:
DISTANCE MBC
9” >150 L/MIN.
6” >60 L/MIN.
3” > 40 L/MIN
 Bed side pulmonary function tests

3)COUGH TEST: DEEP BREATH F/BY COUGH

 ABILITY TO COUGH
 STRENGTH
 EFFECTIVENESS
INADEQUATE COUGH IF: FVC<20 ML/KG
FEV1 < 15 ML/KG
PEFR < 200 L/MIN.

*A wet productive cough / self propagated paraoxysms of

coughing – patient susceptible for pulmonary Complication.
 Bed side pulmonary function tests

4)FORCED EXPIRATORY TIME:

After deep breath, exhale maximally and forcefully & keep
stethoscope over trachea & listen.
N FET – 3‐5 SECS.
OBS.LUNG DIS. ‐ > 6 SEC
RES. LUNG DIS.‐ < 3 SEC
 Bed side pulmonary function tests

5)WRIGHT PEAK FLOW METER: Measures PEFR (Peak Expiratory

Flow Rate)
N – MALES‐ 450‐700 L/MIN.
FEMALES‐ 350‐500 L/MIN.
<200 L/ MIN. – INADEQUATE COUGH EFFICIENCY.
6)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.
DEBONO’S WHISTLE
 Bed side pulmonary function tests

• MICROSPIROMETERS – MEASURE VC.

• BED SIDE PULSE OXIMETRY

• ABG.
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 STATIC LUNG VOLUMES AND
CAPACITIES

• SPIROMETRY : CORNERSTONE OF ALL PFTs.

• John hutchinson – invented spirometer.
• “Spirometry is a medical test that measures the
volume of air an individual inhales or exhales as a
function of time.”
• CAN’T MEASURE – FRC, RV, TLC
 SPIROMETRY‐Acceptability Criteria

• Good start of test‐ without any hesitation

• No coughing / glottic closure
• No variable flow
• No early termination(> 6 sec)
• No air leak
• Reproducibility‐ The test is without excessive variability
The two largest values for FVC and the two largest values for
FEV1 should vary by no more than 0.2L.
SPIROMETRY‐Acceptability Criteria
 Spirometry Interpretation: So what
constitutes normal?

• Normal values vary and depend on:

I. Height – Directly proportional
II. Age – Inversely proportional
III. Gender
IV. Ethnicity
LUNG VOLUMES AND CAPACITIES

PFT tracings have:

Four Lung volumes: tidal
volume, inspiratory reserve
volume, expiratory reserve
volume, and residual volume

Five capacities: inspiratory

capacity, expiratory capacity,
vital capacity, functional residual
capacity, and total lung capacity

Addition of 2 or more volumes comprise a capacity.

 LUNG VOLUMES
• Tidal Volume (TV): volume of
air inhaled or exhaled with
each breath during quiet
breathing (6‐8 ml/kg) 500 ml
• Inspiratory Reserve Volume
(IRV): maximum volume of air
inhaled from the end‐
inspiratory tidal position.3000
ml
• Expiratory Reserve Volume
(ERV): maximum volume of
air that can be exhaled from
resting end‐expiratory tidal
position.1500 ml
 LUNG VOLUMES

• Residual Volume (RV):

– Volume of air remaining in
lungs after maximium
exhalation (20‐25 ml/kg)
1200 ml
– Indirectly measured (FRC‐
ERV)
– It can not be measured by
spirometry .
 LUNG CAPACITIES
• Total Lung Capacity (TLC): Sum of
all volume compartments or
volume of air in lungs after
maximum inspiration (4‐6 L)
• Vital Capacity (VC): TLC minus RV
or maximum volume of air
exhaled from maximal inspiratory
level. (60‐70 ml/kg) 5000ml. VC ~
3 TIMES TV FOR EFFECTIVE
COUGH
• Inspiratory Capacity (IC): Sum of
IRV and TV or the maximum
volume of air that can be inhaled
from the end‐expiratory tidal
position. (2400‐3800ml).
• Expiratory Capacity (EC): TV+ ERV
 LUNG CAPACITIES
• 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
– Decreases
1.in supine position(0.5‐1L)
2.Obese pts
3.Induction of anesthesia: by 16‐
20%
 FUNCTION OF FRC

• Oxygen store
• Buffer for maintaining a steady arterial po2
• Partial inflation helps prevent atelectasis
• Minimizes the work of breathing
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 Measuring RV, FRC

It can be measured by
– nitrogen washout technique
– Helium dilution method
– Body plethysmography
 N2 Washout Technique

• The patient breathes 100% oxygen, and all the

nitrogen in the lungs is washed out.
• The exhaled volume and the nitrogen
concentration in that volume are measured.
• The difference in nitrogen volume at the initial
concentration and at the final exhaled
concentration allows a calculation of
intrathoracic volume, usually FRC.
 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.
• eg: if 50 ml Helium introduced and the helium
concentration is 1% , then volume of the lung is 5L.
 Body Plethysmography

• Plethysmography (derived from greek word meaning

enlargement).

• Based on principle of BOYLE’S LAW(P*V=k)

• Priniciple advantage over other two method is it
quantifies non‐ communicating gas volumes.
• A patient is placed in a sitting
position in a closed body box
with a known volume
• The patient pants with an
open glottis against a closed
shutter to produce changes
in the box pressure
proportionate to the volume
of air in the chest.
• As measurements done at
end of expiration, it yields
FRC
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
FORCED SPIROMETRY/TIMED EXPIRATORY
SPIROGRAM

Includes measuring:
• pulmonary mechanics – to
assess the ability of the lung to
move large vol of air quickly
through the airways to identify
airway obstruction
• FVC
•FEV1
•Several FEF values
•Forced inspiratory rates(FIF’s)
•MVV
 FORCED VITAL CAPACITY

• The FVC is the maximum volume of air that can be

breathed out as forcefully and rapidly as possible
following a maximum inspiration.
• Characterized by full inspiration to TLC followed by
abrupt onset of expiration to RV
• Indirectly reflects flow resistance property of
airways.
FORCED VITAL CAPACITY
 FVC

 Interpretation of % predicted:
 80-120% Normal
 70-79%
 50%-69% Moderate reduction
Mild reduction
 <50% Severe reduction

FVC
 Measurements Obtained from the FVC
Curve and their significance

• Forced expiratory volume

in 1 sec(FEV1 )‐‐‐the
volume exhaled during
the first second of the
FVC maneuver.
• Measures the general
severity of the airway
obstruction
• Normal is 3‐4.5 L
 Measurements Obtained from the FVC
Curve and their significance

FEV1 – Decreased in both obstructive & restrictive lung

disorders(if patient’s vital capacity is smaller than predicted
FEV1).
FEV1/FVC – Reduced in obstructive disorders.
Interpretation of % predicted:
 >75% Normal
 60%‐75% Mild obstruction
 50‐59% Moderate obstruction
 <49% Severe obstruction
Measurements Obtained from the FVC
Curve and their significance
 Forced midexpiratory flow 25‐75% (FEF25‐
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
airways
 Highly variable
 Depends heavily on FVC
• N value – 4.5‐5 l/sec. Or 300
l/min.
Forced midexpiratory flow 25‐75% (FEF25‐
75)

Interpretation of % predicted:
 >60% Normal
 40‐60% Mild obstruction
 20‐40% Moderate obstruction
 <10% Severe obstruction
 Peak expiratory flow rates

• Maximum flow rate during an FVC maneuver occurs in initial

0.1 sec
• After a maximal inspiration, the patient expires as forcefully
and quickly as he can and the maximum flow rate of air is
measured.
• Forced expiratory flow between 200‐1200ml of FVC
• It gives a crude estimate of lung function, reflecting larger
airway function.
• Effort dependant but is highly reproductive
 Peak expiratory flow rates
• It is measured by a peak flow meter,
which measures how much air (litres
per minute)is being blown out or by
spirometry
• The peak flow rate in normal adults
varies depending on age and height.
• Normal : 450 ‐ 700 l/min in males
300 ‐ 500 l/min in females
• Clinical significance ‐ values of <200/l‐
impaired coughing & hence likelihood
of post‐op complication
 Maximum Voluntary Ventilation (MVV) or
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. It is FEV1 * 35
• <80% ‐ gross impairment
 Maximum Voluntary Ventilation (MVV) or
maximum breathing capacity (MBC)
• The subject is asked to breathe as
quickly and as deeply as possible
for 12 secs and the measured
volume is extrapolated to 1min.
• Periods longer than 15 seconds
should not be allowed because
prolonged hyperventilation leads
to fainting due to excessive
lowering of arterial pCO2 and H+.
• MVV is markedly decreased in
patients with
A. Emphysema
B. Airway obstruction
C. Poor respiratory muscle strength
TO SUMMARISE
PHYSIOLOGICAL DETERMINANTS OF MAX.
FLOW RATES

1)DEGREE OF EFFORT‐ driving pressure generated by muscle

contraction (PEmax & PI max)
2) ELASTIC RECOIL PRESSURE OF LUNG: (PL)
 Tendency to recoil or collapse d/t PL
 PL increases from RV (2‐3) to TLC (20‐30)
 Opposed by Pcw (recoil pr. Of chest wall)
 Prs=Pl + Pcw = 0 at FRC‐resting state
(Prs‐recoil pr.of resp.system)
3) AIRWAY RESISTANCE (Raw):
 Determined by the calibre of airways
 Decreases as lung vol increases (hyperbolic curve)
 Raw high at RV & low at TLC
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 FLOW VOLUME LOOPS

 “Spirogram” Graphic analysis of flow at various lung volumes

 Tracing obtained when a maximal forced expiration from TLC
to RV is followed by maximal forced inspiration back to TLC
 Measures forced inspiratory and expiratory flow rate
 Augments spirometry results
 Principal advantage of flow volume loops vs. typical standard
spirometric descriptions ‐ identifies the probable obstructive
flow anatomical location.
 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
• Ratio of
– maximal expiratory flow(MEF)
/maximal inspiratory flow(MIF)
– mid VC ratio and is normally 1
 FLOW VOLUME LOOPS and DETECTION OF
UPPER AIRWAY OBSTRUCTION
• flow‐volume loops provide
information on upper airway
obstruction:
Fixed obstruction: constant
airflow limitation on
inspiration and expiration—
such as
1. Benign stricture
2. Goiter
3. Endotracheal neoplasms
4. Bronchial stenosis
 FLOW VOLUME LOOPS and DETECTION OF
UPPER AIRWAY OBSTRUCTION

Variable intrathoracic obstruction:

flattening of expiratory limb.
1.Tracheomalacia
2. Polychondritis
3. Tumors of trachea or main
bronchus

• During forced expiration – high pleural

pressure – increased intrathoracic pressure ‐
decreases airway diameter. The flow volume
loop shows a greater reduction in the
expiratory phase
• During inspiration – lower pleural pressure
around airway tends to decrease obstruction
 FLOW VOLUME LOOPS and DETECTION OF
UPPER AIRWAY OBSTRUCTION
Variable extrathoracic obstruction:
1.Bilateral and unilateral vocal cord
paralysis
2. Vocal cord constriction
3. Chronic neuromuscular disorders
4. Airway burns
5. OSA
• Forced inspiration‐ negative transmural
pressure inside airway tends to collapse it
• Expiration – positive pressure in airway
decreases obstruction
• inspiratory flow is reduced to a greater extent
than expiratory flow
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 Obstructive Pattern — Evaluation

Common obstructive lung diseases

• Asthma
• COPD (chronic bronchitis, emphysema)
• Cystic fibrosis.
 ASTHMA

 Peak expiratory flow reduced so

maximum height of the loop is
reduced
 Airflow reduces rapidly with the
reduction in the lung volumes
because the airways narrow and
the loop become concave
 Concavity may be the indicator of
airflow obstruction and may
present before the change in FEV1
or FEV1/FVC
 EMPHYSEMA

Airways may collapse during

forced expiration because of
destruction of the supporting lung
tissue causing very reduced flow at
low lung volume and a
characteristic (dog‐leg) appearance
to the flow volume curve
 REVERSIBILITY

• Improvement in FEV1 by 12‐15% or

200 ml in repeating spirometry after
treatment with Sulbutamol 2.5mg or
ipratropium bromide by nebuliser
after 15‐30 minutes
• Reversibility is a characterestic
feature of B.Asthma
• In chronic asthma there may be only
partial reversibility of the airflow
obstruction
• While in COPD the airflow is
irreversible although some cases
showed significant improvement
 RESTRICTIVE PATTERN

Characterized by reduced lung

volumes/decreased lung
compliance
Examples:
•Interstitial Fibrosis
•Scoliosis
•Obesity
•Lung Resection
•Neuromuscular diseases
•Cystic Fibrosis
 RESTRICTIVE PATTERN‐flow volume loop
• low total lung capacity
• low functional residual capacity
• low residual volume.
• Forced vital capacity (FVC) may be
low; however, FEV1/FVC is often
normal or greater than normal due
to the increased elastic recoil
pressure of the lung.
• Peak expiratory flow may be
preserved or even higher than
predicted leads to tall,narrow and
steep flow volume loop in
expiratory phase.
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests for gas exchange function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 TESTS FOR GAS EXCHANGE FUNCTION

ALVEOLAR‐ARTERIAL O2 TENSION GRADIENT:

 Sensitive indicator of detecting regional V/Q inequality
 N value in young adult at room air = 8 mmHg to up to 25
mmHg in 8th decade (d/t decrease in PaO2)
 AbN high values at room air is seen in asymptomatic smokers
& chr. Bronchitis (min. symptoms)
A‐a gradient = PAO2 ‐ PaO2
* PAO2 = alveolar PO2 (calculated from the alveolar gas
equation)
* PaO2 = arterial PO2 (measured in arterial gas)
PAO2:
(PB ‐ PH2O)*FiO2 ‐ (PaCO2/RQ)
 TESTS FOR GAS EXCHANGE FUNCTION

DIFFUSING CAPACITY
• Rate at which gas enters the blood divided by its driving pressure
( gradient – alveolar and end capillary tensions)
• Measures ability of lungs to transport inhaled gas from alveoli to
pulmonary capillaries
• Normal‐ 20‐30 ml/min/mm Hg
• Depends on:
‐ thickeness of alveolar—capillary membrane
‐ hemoglobin concentration
‐ cardiac output
 TESTS FOR GAS EXCHANGE FUNCTION

SINGLE BREATH TEST USING CO

• Pt inspires a dilute mixture of CO and hold the breath for 10 secs.
• CO taken up is determined by infrared analysis:
• DlCO = CO ml/min/mmhg
PACO – PcCO
• DLO2 = DLCO x 1.23
• Why CO?
A) High affinity for Hb which is approx. 200 times that of O2 , so
does not rapidly build up in plasma
B) Under N condition it has low bld conc ≈ 0
C) Therefore, pulm conc.≈0
 FACTORS EFFECTING DLCO

DECREASE(< 80% predicted) INCREASE(> 120‐140%

predicted)
Anemia Polycythemia
Carboxyhemoglobin Exercise
Pulmonary embolism Congestive heart failure
Diffuse pulmonary fibrosis
Pulmonary emphysema

Predicted DLCO for Hb= Predicted DLCO * (1.7 Hb/10.22 + Hb)

 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 CARDIOPULMONARY INTERACTION

• Stair climbing and 6‐minute walk test

• This is a simple test that is easy to perform with minimal
equipment. Interpretated as in the following table:
Performance VO2 Interpretation
max(ml/kg/min)
>5 flight of stairs > 20 Low mortality after
pneumonectomy, FEV1>2l
>3 flight of stairs Low mortality after lobectomy,
FEV1>1.7l
<2 flight of stairs Correlates with high mortality
<1 flight of stairs <10
6 min walk test <600 m <15
 CARDIOPULMONARY INTERACTION

• Shuttle walk
• The patient walks between cones 10 meters apart with
increasing pace.
• The subject walks until they cannot make it from cone to
cone between the beeps.
• Less than 250m or decrease SaO2 > 4% signifies high risk.
• A shuttle walk of 350m correlates with a VO2 max of 11ml.kg‐
1.min‐1
 Cardiopulmonary Exercise Testing

 Non invasive technique

 Effort independent
 To test ability of subjects physiological response to
cope with metabolic demands
 Basic Physiological Principles

• Exercising muscle gets energy from 3 sources‐ stored energy

(creatine phosphate), aerobic metabolism of glucose,
anaerobic metabolism of glucose
• In exercising muscle when oxygen demand exceeds supply‐
lactate starts accumulating‐ lactate anaerobic threshold (
LAT)
• With incremental increase in exercise – expired minute
volume, oxygen consumption per minute, CO2 production
per minute increases
 What To Measure

◦ Anaerobic threshold (> 11 ml/kg/min)

◦ Maximum oxygen utilization VO2 (>20ml/kg/min)
◦ Ventilatory equivalent of O2 (< 35L)
◦ Ventilatory equivalent of CO2 (<42L)
◦ Oxygen pulse (4‐6ml/heart beat)
 INDEX

1. Bedside pulmonary function tests

2. Static lung volumes and capacities
3. Measurement of FRC, RV
4. Dynamic lung volumes/forced spirometry
5. Flow volume loops and detection of airway obstruction
6. Flow volume loop and lung diseases
7. Tests of gas function
8. Tests for cardiopulmonary reserve
9. Preoperative assessment of thoracotomy patients
 Assessment of lung function in
thoracotomy pts

• As an anesthesiologist our goal is to :

1) to identify pts at risk of increased post‐op morbidity &
mortality
2) to identify pts who need short‐term or long term post‐op
ventilatory support.
Lung resection may be f/by – inadequate gas exchange, pulm
HTN & incapacitating dyspnoea.
 Assessment of lung function in
thoracotomy pts
Calculating the predicted postoperative
FEV1 (ppoFEV1) and TLCO (ppoTLCO):
There are 5 lung lobes containing
19 segments in total with the division of each
lobe.
Ppo FEV1=preoperative FEV1 * no. of segments
left after resection
19
• Can be assessed by ventilation perfusion scan. For eg:
A 57-year-old man is booked for lung
resection. His CT chest show a large RUL
mass confirmed as carcinoma:
ppoFEV1= 50*16/19=42%
 Assessment of lung function in
thoracotomy pts
ppoFEV1(% predicted) Interpretation
> 40 No or minor respiratory complications
anticipated
< 40 Likely to require postoperative
ventilation/increased risk of
death/complication
< 30 Non surgery management should be
considered

ppoDLCO(% predicted) Interpretation

> 40,ppoFEV1> 40%,SaO2>90% on air Intermediate risk , no further investigation
needed
< 40 Increased respiratory and cardiac morbidity
< 40 and ppoFEV1<40% High risk‐ require cardiopulmonary exercise
test
In addition to history , examination , chest X‐ ray, PFT’s pre‐ op
evaluation includes:
• ventilation perfusion scintigraphy/ CT scan

• split‐lung function tests

 methods have been described to try and simulate the
postoperative respiratory situation by unilateral exclusion of a
lung or lobe with an endobronchial tube/blocker or by
pulmonary artery balloon occlusion of a lung or lobe artery
 Combination tests

• There is no single measure that is a ‘Gold standard ‘

in predicting post‐op complications

Three legged stool

Cardiopulmonary
Respiratory Lung parenchymal
reserve
mechanics function
Vo2max (>15ml/kg/min)
DL co (ppo>80%)
Stair climb > 2 flights, 6
FEV1(ppo>40%) PaO2>60
min walk,
MVV,RV/TLC,FVC Paco2<45
Exercise Spo2 <4%
 Pulmonary function criteria suggesting increased risk of post‐
operative pulmonary complications for various surgeries

Parameters Abdominal Thoracic

FVC < 70 % predicted < 2 lit. or < 70% predicted

FEV1 < 70 % predicted < 2 lit. – pneumonectomy

< 1 lit. – lobectomy
< 0.6 lit. – wedge or segmentectomy

FEV1/FVC < 65 % predicted < 50 % predicted

FEF 25‐75 % < 50 % predicted < 1.6 lit. – pneumonectomy

< 0.6 lit.‐ lobectomy/segmentectomy

MVV/MBC < 50 % predicted < 50 % predicted

PaCO2 > 45 mm Hg > 45 mm Hg

 Look at flow-vol loop and any
airway obstruction pattern

FEV1 /VC >LLN

Yes No
VC >LLN VC >LLN

No No
Yes TLC >LLN TLC >LLN
Yes Yes
No Yes No

Normal Restriction Obstruction mixed defects

DLCO>LLN DLCO>LLN DLCO>LLN

Yes No Yes No
Pulmonary Yes
No Asthma , bronchitis Emphysema
Normal Vascular Ds
Neuromuscular
diseases &chest ILD & pneumonitis
wall ds
Yes, PFTs are really wonderful but… They do not
act alone.

• They act only to support or exclude a

diagnosis.
• A combination of a thorough history and
physical exam, as well as supporting
laboratory data and imaging is helpful in
developing a anaesthetic plan for pt with
pulmonary dysfunction.