PULMONARY

FUNCTION
TESTS
-Tvisha Patel.
 INTRODUCTION
 Pulmonary Function Tests help in the evaluation of the
mechanical function of the lungs.
 They are based on researched norms taking into account
sex, height and age.
e.g. There are predicted values for a male of 65 year age,6
feet tall. When patient performs the tests, the actual results
will be compared with the predicted value of a person of a
particular(sex, height, age) to see if he falls within normal
ranges or has a restrictive or obstructive component based
tests.
 Obstructive and restrictive lung
diseases
RESTRICTIVE LUNG DISEASE – Any abnormal respiratory
condition, which makes it di cult to get air into the lungs
- inspiration is a ected expiration is not
OBSTRUCTIVE LUNG DISEASE – Any abnormal respiratory
condition, which makes it di cult to push air outside the lungs

Mixed: less common.

Pathology
OBSTRUCTIVE LUNG
DISEASE
RESTRICTIVE LUNG DISEASE
COMPARISON BETWEEN OBSTRUCTIVE AND RESTRICTIVE LUNG
DISEASES
CHARACTERISTICS OBSTRUCTIVE RESTRICTIVE
DISEASE DISEASE
ANATOMY Airways Lung parenchyma
AFFECTED
BREATHING PHASE Expiration Inspiration
DIFFICULTY
PATHOPHYSIOLOG Increase in Decrease in lung
Y airway resistance or thoracic
compliance
USEFUL Flow rates Volumes and
MEASUREMENTS Capacities
 PURPOSE OF THE PFTs
1. To identify and quantify changes in pulmonary function
2. To help de ne more clearly the type of functional disorder
3. To know whether its obstructive or restrictive lung disease
4. Epidemiological surveillance for pulmonary disease
5. Assessment of post operative pulmonary risk
6. To aid in determination of pulmonary disability
7. To evaluate and quantify therapeutic e ectiveness
 Indications of pfts
1. Initial and segmental evaluation of patient with exertional /
paroxysmal dyspnea
2. Initial and segmental evaluation of case of known
respiratory disorder
3. Di erential diagnosis of lung disorders
4. Objective assessment of patients with chest problems. E.g.
cough, chest pain. if average FEV1 < 50%, then associated
risks are higher after surgery
5. Fitness for surgery, particular heart/lung
6. Guidelines for therapy in respiratory disorders and drug
evaluation. E.g. bronchodilator
7. Degree of disability and association of occupational lung
disease
8. Research purposes
9. E ect of training and selection of athletes
 PULMONARY FUNCTION TESTS MEASURES
1. LUNG VOLUMES AND CAPACITIES
2. FLOW RATES OF GASES THROUGH AIRWAYS
3. ABILITY OF THE LUNGS TO DIFFUSE GASES( di usion)

 PFTs do not dispose speci c pulmonary disease, but

identi es the presence and degree of pulmonary
impairments as well as type of pulmonary disease present.
 ORGANIZATION
 To measure each component, variety of technique and
equipments are used.
 Common regimen of PFT in laboratory is to evaluate the
e ectiveness of bronchodilator therapy.
 Pulmonary mechanics especially the FEV1 (FORCED
EXPIRATORY VOLUME IN 1 SECOND) are measured as a
baseline.
 Then patient uses bronchodilator by inhalation of a diluted
aerosol or by metered-dose inhaler.
 Measurements of pulmonary mechanics are updated and the
present change is calculated according to following equation:
% change=(posttest FEV1 -pretest FEV1)/pretest FEV 1*100
An increase in FEV1 more than 15% indicates bene cial e ects
of medication.
 EQUIPMENTS
Instruments used are:
A. Devices that measure gas volume
i. Water-sealed spirometers
ii. Bellow-spirometers
iii. Dry rolling seal spirometers
B. Devices that measures gas ow
i. Pneumotachometers
ii. Thermistors
iii. Turbinometers
iv. Sonic devices
v. Peak ow meters
 Each instrument has – CAPACITY,ACCURACY,ERROR,
PRECISION,LINEARITY AND OUTPUT.
 Pulmonary function testing is safe, but a possibility of cross
contamination exists, either from patients or from
technologists.
 BELLOW
SPIROMETE
R

DRY ROLLING SEAL

SPIROMETER
 PNEUMOTACHOMETER

PEAK FLOW METER

 PRINCIPLES OF MEASUREMENT
1. LUNG VOLUMES
Lung has four volumes:
TIDAL VOLUME – The volume of air breathed in and out in a
single normal quiet breath is Tidal Volume.
Normal value – 500ml
INSPIRATORY RESERVE VOLUME – Maximal amount of
air that can be inhaled from end normal INSPIRATION.
Normal Value – 3100 ml
EXPIRATORY RESERVE VOLUME – Maximal amount of air
that can be exhaled after a normal exhalation.
Normal Value – 1200ml
RESIDUAL VOLUME – Volume of air that remains in the
lungs at the end of maximum expiration.
Normal Value – 1200ml
2.TwoLUNG CAPACITIES
or more lung volumes are together called Lung Capacities.
The four lung capacities are:
INSPIRATORY CAPACITY – It is the maximum volume of air
that can be inspired from end expiratory position.
IC =TV + IRV
=500 +3100
= 3600 ml
VITAL CAPACITY – It is the maximum amount of air that can
be expelled out forcefully after maximal deep inspiration.
VC =IRV + TV + ERV
=3100 +500 +1200
=4800 ml
FUNCTIONAL RESIDUAL CAPACITY – It is the volume of air
remaining in the lungs after normal expiration.
FRC = ERV + RV
=1200 +1200
= 2400 ml
TOTAL LUNG CAPACITY – It is the amount of air present in the
lungs after a maximal deep inspiration.
TLC = (IRV + TV + ERV) + RV
= VC + RV
= 4800 + 1200
=6000 ml
MEASUREMENTS OF LUNG VOLUMES
AND

CAPACITIES
Lung Volumes and capacities are measured by instrument
called SPIROMETER.
 Modi ed spirometer is called respirometer.

SPIROMETER
 Upward curve of graph shows inspiration and downward
de ection denotes expiration in spirogram.
 It can be used only for a single breath.
 Repeated cycles of respiration cannot be recorded by using
this because ,CO2 accumulated in the spirometer cannot be
removed and the O2 or fresh air cannot be provided to the
subject.
RESPIROMETER
 It is modi ed spirometer.
 It has provision for removal of CO2 and supply of O2.
 CO is removed by placing soda lime inside the instrument.
SPIROGRAM
Recording of lung volumes and capacities using spirometer
or respirometer is called SPIROGRAM.
SPIROGRAM
Four levels are noted in spirogram:
 The normal end expiratory level
 The normal end inspiratory level
 Maximum expiratory level
 Maximum inspiratory level
COMPUTARISED SPIROMETER
It is an electronic equipment, which does not contain a drum
or water chamber. Subject has to respire into a sophisticated
transducer, which is connected to the instrument by means of
a cable.
DISADVANTAGES

OF SPIROMETRY
Residual volume cannot be measured by this.
 FRC & TLC also can not be measured.
 MEASUREMENT OF FRC,RV AND TLC
 Volume and capacities which cannot be measured by spirometry
can be measured by the following methods:
1) HELIUM DILUTION TECHNIQUE
2) NITROGEN WASHOUT METHOD
3) PLETHYSMOGRAPHY
 HELIUM DILUTION METHOD
 It is a procedure to measure FRC
 Respirometer is lled with air containing a known quantity of
helium
 Subject breathes normally. After end of expiration, subject
breathes from Respirometer.
 Helium from Respirometer enters lungs and starts mixing with
air in the lungs
 After few minutes of breathing, the concentration of helium in
the Respirometer becomes equal to the concentration of helium
in the lungs of subject. This is called as EQUILIBRIUM OF HELIUM
 After equilibrium of helium in Respirometer and lungs, the
concentration of helium in Respirometer is determined
 It takes about 5 min for equilibrium of Helium between patient
and spirometer to occur. In obstructive disease, it can take up
to 30 min.
FRC = V(C1 – C2) / C2
C1= initial concentration of helium in the respirometer
C2= nal concentration of helium in the respirometer
V= initial volume of air in the respirometer

HELIUM DILUTION METHOD

 NITROGEN WASHOUT METHOD
 Concentration of nitrogen in air is 80%.So, if the total quantity of
nitrogen in the lungs can be measured, the amount of air present in
the lungs can be calculated.
PROCEDURE TO MEASURE FRC
 Subject is asked to breath normally
 At the end of normal expiration, subject inspires pure O2
through a valve and expires into Douglas bag
 This procedure is repeated for 6-7 min, until the nitrogen in
lungs is displaced by O2
 Nitrogen comes to the Douglas bag
 Following factors are measured to calculate FRC
I. Volume of air collected in the Douglas bag
II. Concentration of nitrogen in Douglas bag
FRC=C1 * V/C 2
V=VOLUME OF AIR COLLECTED
C1=CONCENTRATION OF NITROGEN IN THE COLLECTED AIR
C =NORMAL CONCENTRATION OF NITROGEN IN AIR
NITROGEN WASHOUT METHOD
 PLETHYSMOGRAPHY
 Plethysmography is a technique to study the variation in size or
volume of a part of the body such as a limb
 Whole body plethysmography is the instrument used to measure
the lung volumes including RV
 It is based on Boyles’ law of gas, which states that the volume of a
sample of a gas is inversely proportional to the pressure of that gas
at constant temperature.

METHOD
Subject sits in an airtight chamber of the whole body
plethysmography and breathes normally through a mouthpiece
connected to a ow transducer called PNEUMOTACHOGRAPH
 It detects the volume changes during di erent phases of respiration
 After normal breathing for few minutes, the subject breathes
rapidly with maximum force
 During maximum expiration, lung volume decreases very much
 But volume of gas in chamber increases within pressure
 By measuring the volume and pressure changes inside the
chamber, the volume of lungs can be calculated by using the
formula
P1 * V = P2(V- V)
V = P2(V- V)/P1
P1 and P2 = pressure changes
V=FRC
 Pulmonary mechanics
Tests of pulmonary mechanics include measurement of :
1. FEV – Forced Expiratory Volumes
2. FIF – Forced Inspiratory Flow rates
3. FEF – Forced Expiratory Flow rates
4. MVV – Maximum Voluntary Ventilation

 Measuring pulmonary mechanics is assessing the ability of lungs to

move large volume of air quickly to identify airway obstruction
 Some measurements aimed at large intrathoracic airways, some at
small airways and some assess obstruction throughout the lungs
Forced expiratory volume (fev) / timed vital
capacity
Amount of air, which can be expired forcefully in a given unit
of time(after a deep inspiration) is called FEV
 FEV1 – Amount of air expired forcefully in 1 sec
 FEV2 – Amount of air expired forcefully in 2 sec
 FEV3 – Amount of air expired forcefully in 3 sec

NORMAL VALUES
FEV1 – 83% Of TVC
FEV2 – 94% of TVC
FEV3 – 97% of TVC
After 3rd sec = 100% of TVC
SIGNIFICANCE OF FEV
 Vital capacity may be normal in some of the respiratory
diseases
 FEV has greater diagnostic value as it is decreased
signi cantly in some respiratory disorders
 FEV decreases much in obstructive diseases like – ASTHMA
& EMPHYSEMA
 In some restrictive diseases like brosis FEV is slightly
increased
 Signi cance of fev1
 Re ects the air ow in larger airways
 The utility of the FEV1 measurement is exempli ed by the simple
relationship between it and the associated degree of obstruction
Little or no obstruction FEV1 above 2.0 L to normal
Mild to moderate FEV1 between 1.0 L to 2.0 L
obstruction
Severe obstruction FEV1 less than 1.0 L

 Normally, 75% of the FVC should be exhaled within I second. An

FEV1 % of more than 80% or 90% indicates restrictive condition,
while reduced FEV1 % indicates airway obstruction.
SADOWSKY
 Respiratory minute volume(RMV)
Amount of air breathed in and out of lungs every minute is
called RESPIRATORY MINUTE VOLUME.
It is the product of Tidal Volume (TV) and Respiratory Rate (RR)
RMV = TV * RR
= 500 * 12
= 6000 ml
NORMAL RMV = 6 liters
VARIATIONS
RMV increases in physiological condition like voluntary
hyperventilation, exercises and emotional conditions
 It decreases in respiratory disorders
 Maximum breathing capacity(mbc) / MAXIMUM
VOLUNTARY VENTILATION (MVV)
Maximum amount of air which can be breathed in and out of lungs by
means of forceful respiration (hyperventilation increase in rate and
force of respiration) per minute is called MAXIMUM BREATHING
CAPACITY or MAXIMUM VOLUNTARY VENTILATION
NORMAL VALUE
Males – 150-170 l/min
Females – 80-100 l/min


MEASUREMENT
Subject is asked to breathe forcefully and rapidly with respirometer
for 12 secs
 Amount of air inspired and expired is measured from spirogram
 From this, MBC is calculated from one minute
MBC per min = n/12 * 60 liters(e.g. MBC in 12 sec =n liters)
MBC is reduced in respiratory diseases.
 It re ects strengths and endurance of the respiratory muscles
 Maximum voluntary ventilation (MVV) is the maximal volume of
gas a patient can move during 1 minute.
 However normal values can vary as much as 25% t0 30%:
therefore, only major reductions in the values are clinically
signi cant.
 As a rule of thumb MVV is typically described as being about 35
times greater than the FEV1.

sadowsky
 Slow vital capacity(svc)
 The slow vital capacity (SVC) – also called the vital capacity (VC) – is
similar to the FVC, but the exhalation is slow rather than being as rapid as
possible as in the FVC. In a normal subject, the SVC usually equals the
FVC, while in patients with an obstructive lung disorder ,the SVC is usually
larger than the FVC. The reason for this is that, in obstructive lung
disorders, the airways tend to collapse and close prematurely because of
the increased positive intrathoracic pressure during a forceful expiration.
This increased pressure leads to air trapping. Accordingly, a signi cantly
higher SVC compared with FVC suggests air-trapping
 Peak expiratory ow rate (PEFR)
Maximum rate at which the air can be expired after a deep
inspiration is known as PEFR
NORMAL VALUE- 400 L/min
MEASUREMENT
 Determined by using – WRIGHT’S PEAK FLOWMETER / MINI PEAK
FLOWMETER
 From a position of full inspiration, air is forcibly expired across a
pivoted vane or a lightweight piston.
 The displacement of vane or piston is proportional to maximum
ow rate.
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SIGNIFICANCE OF PEFR
 It is useful for assessing respiratory diseases especially to
di erentiate obstructive and restrictive diseases.
 PEFR is decreased in any type of respiratory disease
 It is more signi cant on obstructive (100 L/min) than in restrictive
(200 L/min)

www.docstock.com-Clement
Clarke
 FLOW VOLUME CURVE
The ow volume procedure simply reports ow against volume on
X-Y recorder
Helps in diagnosing lung disease, since it is independent of e ort.
 Curve below demonstrates that ow rises to a high value and then declines
over most of expiration
 In restrictive lung diseases – the maximum ow rate is decreased, as it is
the total volume exhaled
 In obstructive lung disease – the ow rate is low in relation to the lung
volume and a scooped out graph is seen
 Following a period of normal
quiet
breathing' patient is instructed to
perform a maximal inspiration to
hold the breath for I or 2 secand
then expire fully

sadowsky
FLOW VOLUME LOOP
 It is a diagnostic test that uses forced expiration
 It is a graphical analysis of the ow generated during a forced
expiratory volume maneuver followed by a forced inspiratory
volume maneuver
 Shape of graph helps to diagnose disease

 Obstructive disease- scooped out appearance

AIRWAY DIVISION
CLASSIFICATION OF OLD
 Upper airway obstruction
Flow Volume loop MUST be recorded to diagnose UAO.
It can be ….
1) FIXED – UAO remains unchanged during
inspiration and expiration
2) VARIABLE (Extrathoracic & Intrathoracic)
UAO degree changed during inspiration and
expiration
Empley’s index helps to CONFIRM presence and
Identify type of UAO.
 Fixed UA obstruction
1. Post intubation tracheal
stricture
2. Large Goiter
3. Endotracheal neoplasms
4. Tracheal stenosis

Maximum air ow is limited to a

similar extent in both
inspiration and expiration so it
give “BOX ” like look on FV loop.
In Large goiter FV loop is Normal
when sitting so its better to do
Spirometry in supine position
 Variable extrathoracic obstruction
Causes :
1. Bilateral and unilateral vocal cord
paralysis
2. Vocal cord constriction
3. Hypertrophied tonsils and Adenoids
4. Airway burns
5.Pharyngeal and Laryngeal growth
The obstruction worsens in inspiration
because the negative pressure
narrows the trachea and inspiratory
ow is reduced to a greater extent
than expiratory ow so it show
FLATTNING of the inspiratory curve
of FV loop
 Variable intrathoracic obstruction
Causes:
1. Tracheomalacia
2. Polychondritis
3. Tumors of the lower trachea or
main bronchus.
4. Excessive mucus plugging
5. Mediastinal mass compressing
trachea
6. Aortic aneurysm
The narrowing is maximal in
expiration because of increased
intrathoracic pressure
compressing the airway.
The ow volume loop shows a
FLATTENING of expiratory curve.
 Emphysema

Airways may collapse

during forced expiration
because of destruction of
the supporting lung tissue
causing very reduced
ow at low lung volume
and a characteristic (dog-
leg) appearance to the
ow volume curve.
 Restrictive lung disease
A characteristic pattern
in restrictive lung
disease is “Normal
shaped, Miniature
graph” due to
reduction of the ow
rate along with
reduction of FVC.
Neuromuscular restrictive lung disease

1. Generalized Weakness - malnutrition

2. Paralysis of the diaphragm
3. Myasthenia Gravis
4. Muscular Dystrophy
5. Poliomyelitis
6. Amyotrophic Lateral Sclerosis - Lou Gerig's Disease
MEASUREMEN NORMAL OBSTRUCTIVE RESTRICTIVE
T
TIDAL 500 ml N / increased N / decreased
VOLUME
IRV 3300 ml N / decreased decreased
ERV 1200 ml N / decreased decreased
RV 1200 ml increased decreased
IC N / increased decreased
FRC increased decreased
TLC 6000 ml N / increased Decreased
FVC 4800 ml Decreased Decreased
FEV1 4200 ml Decreased N / decreased
FEV1/FVC >70% Decreased N / increased
 DIFFUSION CAPACITY OF LUNG
 Third major category of pulmonary function testing is measuring
the ability of the lungs to transfer gases across the alveolar
capillary membrane
 The di usion capacity of lung or Dlco or sometimes called as
TRANSFER FACTOR
 It is expressed in ml/min/mm Hg under standard temperature and
pressure and dry conditions(STPD)
 Gas normally used to measure the di using capacity of lung is
CO(carbon monoxide) according to following equation:
DLCO= VE(FI CO – FECO)/(PACO – PcCO)
DLCO = 25-30 ml/min/mm Hg
VE= volume
FI CO = concentration of CO in inhaled air
FECO = concentration of CO in exhaled air
PACO = alveolar partial pressure of CO
P CO = partial pressure of CO in pulmonary capillary plasma
 COMMON METHODS USED ARE:
1. SINGLE BREATH – requires patients co operation and breath
holding
2. STEADY STATE TECHNIQUE – uses normal breathing pattern
 Carbon monoxide (CO) is normally employed as a measure
Di usion of gases because it has an a nity for hemoglobin nearly
210 times greater than that of oxygen. As long as person’s Hb is
normal the alveolar CO should bind to the Hb and the partial
pressure of CO in plasma is zero
 The normal di using capacity of carbon monoxide is about 25 to
30 mL/min/mm Hg.
 Although there may be many causes for an abnormal DLCO test,
they can be attributed to three key factors:
(1) decreased quantity of hemoglobin per unit volume of blood
(2) increased thickness of the alveolar-cappillary membrane
(3) decreased functional surface area available for di usion
sadowsky
 LIMITATIONS OF PFT

1. Tests cannot reveal patient disease unless the function are

su ciently lower
2. Tests do not provide anatomical diagnosis but can help
localizing it to a section of airway/lung
3. Tests fail to localize disease process except when lungs/lobes
are tested separately
4. Tests must be multiple since no single test can evaluate total
abnormality at one time
 References

 Principles and practice of cardiopulmonary physical

therapy (third edition) – DONNA FROWNFELTER &
ELIZABETH DEAN
 EGAN’s fundamentals of respiratory care (seventh edition)

 Essentials of Cardiopulmonary physical therapy –ELLEN

HILEGASS & STEVEN SADOWSKY
 CASH’s textbook of chest, heart and vascular disorders for
physiotherapists
 Essentials of medical physiology – K SEMBULINGAM &
PREMA SEMBULINGAM