Taibah University

College of Medical Rehabilitation Sciences

Respiratory Therapy Department
Basic Pulmonary Function Testing (RT 336)

Basics, Current Recommendations

for performing PFT

Dr. Naseer Ahmad

Taibah University
Basics, Current Recommendations & interpretation of PFT

Objectives
1. Identify the components of PFTs

2. Describe the indications

3. Apply this information to patient care

Pulmonary function tests (PFTs)

o Pulmonary function testing is a valuable tool for evaluating the

respiratory system
o comparing the measured values for pulmonary function tests obtained on a
patient at any particular point with normal values derived from population
studies.
o

o The percentage of predicted normal is used to grade the severity of the

abnormality.
Pulmonary function tests

PFTs
o Four lung components include :
❖ The airways (large and small)
❖ Lung parenchyma (alveoli, interstitium)
❖ Pulmonary vasculature
❖ The bellows-pump mechanism

o PFTs can include: simple screening spirometry, Flow Volume Loop, Formal
lung volume measurement, Bronchoprovocation testing, Diffusing capacity for
carbon monoxide, Arterial blood gases, Measurement of maximal respiratory
pressures

o These studies may collectively be referred to as a complete pulmonary

function survey.
Pulmonary function tests classification

PFT can be classified into :

1. Tests of ventilatory functions include:
A. Tests use to evaluate lung volumes and capacities which are:
a. Spirometry
b. Gas dilution method
c. Body plethysmography
B. Tests of airways hyper-reactivity(broncho-provocation tests)

2. Tests use to evaluate lung compliance.

3. Tests of gas exchange:
A. tests of diffusion (Diffusing lung capacity)
B. Blood gas analysis
4. Assessment of regional lung functions
Spirometry (meaning the measuring of breath)

Spirometry: A technique used to measure air flow in and out of the

lungs during controlled ventilatory maneuvers. It includes the
recording of lung volumes and capacities defined by the respiratory
process. These recordings may be static (untimed) or dynamic
(timed). Spirometry Assesses the integrated mechanical functions of
lungs, chest wall and respiratory muscles.

o Spirometer is the device

o Please note that: Patients and physicians have inaccurate
perceptions of severity of airflow obstruction and/or severity of
lung disease by physical exam
o It provides objective evidence in identifying patterns of disease
Spirometry

o Often done as a maximal expiratory maneuver

o Spirometry is the most common used lung function screening study.
o Should be the clinician's first option
o Other studies being reserved for specific indications
Advantages of spirometer :
o Easily performed
o Can be done in the ambulatory setting, physician's office, emergency
department, or inpatient setting.
o It is Simple and no need for gases or additional devices
o It can Measure flow, volumes
o It can measure Volume vs. Time
Spirometry

Can determine (according to device ):

❖ Slow vital capacity (VC)
❖ Forced expiratory volume in one second (FEV1)
❖ Forced vital capacity (FVC)
❖ FEV1/FVC
❖ Forced expiratory flow 25%-75% (FEF25-75)
❖ Peek expiratory flow rate (PEFR)
❖ Maximum voluntary ventilation (MVV )

Can not measure RV,FRC,TLC

Spirometer devices
There are two types of spirometers: 1-Volume spirometer. 2-Flow spirometer.
Please note the difference between the following
1.Flow Sensitive Spirometer :
• Utilize a sensor that measures air flow as the primary signal and calculate volume by integration
• Automatically calculate a wide range of ventilatory indices and draw curves, which provide an
immediate feedback on quality.
• Easier for the patient and operator.
• Easy disinfection, some have disposable flow sensors eliminating the need for disinfection.
• Can be office based or portable.
• Some devices can be connected to computer to obtain data
2.Peak flow meter
• Portable
• Readings have limited accuracy and are flow dependent.
• Limited role in initial assessment of respiratory disease.
• Reasonably reliable for patients to monitor their own disease progression or response to therapy.
3.Incentive Spirometer (not used to measure lung function. It is used to improve it)
•It is not a diagnostic tool, it is used to improve the patient incentives to comply with treatment and to do
respiratory exercises
 Devices

Spirometer (office) Spirometer (hand held) Spirometer (home)

Incentive spirometer
Peak flow meter
Indications of PFT
1. Symptoms and clinical signs
➢ Dyspnea with or without or wheezing
➢ Chest pain or orthopnea
➢ Chronic Cough with or without phlegm production
➢ Cyanosis, Decreased or unusual breath sounds
2. Abnormal chest x-ray (e.g. Hyperinflation)
3. Abnormal blood gases (hypoxemia, hypercapnia)
4. Abnormal laboratory findings (e.g. polycythemia)
5. Monitoring of known pulmonary diseases
6. 6. Diagnosis of lung disease
7. Assessing severity or progression of disease (e.g. asthma, COPD)
➢ Control of therapy, e.g. Bronchodilatator or steroids.
➢ Assessing reversibility (asthma versus COPD)
8. Preoperative assessment
9. Further Indications for spirometry:
➢ Periodic examinations in high-risk groups
➢ Course of FEV1 in smokers
➢ Risk stratification of patients for surgery
➢ Check-up
➢ Evaluating disability or impairment
➢ Extrapulmonary diseases with lung involvement
Indications of PFT continue ………….

Prognostic indications
o Assess severity of lung disease

o Follow response to therapy

o Determine further treatment goals

o Referral for surgery

o Disability assessment
Contraindications of PFT

Relative contraindications of PFT

1.Acute disorders affecting test performance (e.g. vomiting, nausea, vertigo)
2.Hemoptysis of unknown origin (FVC maneuver may aggravate underlying
cause)
3.Pneumothorax
4.Recent abdominal or thoracic surgery
5.Recent eye surgery (increases in intraocular pressure during spirometry)
6.Recent myocardial infarction or unstable angina
7.Thoracic, abdominal, or cerebral aneurysms (risk of rupture because of
increased thoracic pressure)
8.patients with a history of syncope associated with forced exhalation
Possible side effects or complications of spirometry

1.Serious complications are rare Syncope, dizziness, light-

headedness
2.Paroxysmal coughing
3.Bronchospasm (e.g. Asthma)
4.Increased intracranial pressure
5.Thoracic pain
6.Pneumothorax (very rare)
7.Contraction of nosocomial infections (very rare)
Lung Factors Affecting Spirometry

➢ Mechanical properties
➢ Resistive elements
Infection control and safety during PFT
Infection control and safety during spirometry
1.Spirometers should be cleaned according to the manufacturer´s
recommendations
2.The mouthpiece, nose clips, tubing, and any parts of the instrument that come
into direct contact with a patient should be disposed, sterilized, or disinfected
between patients.
3.Any equipment surface showing visible condensation from exhaled air should
be discarded, disinfected, or sterilized before reuse.
4.Change of mouthpiece: the change of the mouthpiece should be visible to the
patient. Alternatively disposable bacteria filters should be used.
5.Bacterial filters should always be used in infectious pts (e.g. MRSA, HIV,
hepatitis B, TB), as well as in patients with immunodeficiency (e.g.
chemotherapy, post-transplantation, CF).
6.A mask should be worn by the technologist when testing subjects who have
active TB or other serious diseases that can be transmitted by coughing.
7.Proper hand washing & Gloves should be worn when handling potentially
contaminated equipment.
8.Practitioners should wear gloves when handling potentially contaminated
mouthpieces, valves, tubing, and equipment surfaces.
9.When performing procedures on patients with potentially infectious airborne
diseases, practitioners should wear a personal respirator or a close-fitting surgical
mask, especially if the testing induces coughing.
10.Practitioners should always wash their hands between testing patients and after
contact with testing equipment.
 Preparation & Instructions given to patient before PFT
Patient Instructions Prior to Testing should be given to patient at time of appointment
➢ Should wait at least one month post MI, consider impact of problems that may
affect results (chest/abdominal pain, oral or facial pain, stress incontinence,
dementia, physical deformities or medical conditions)
➢ Physical and mental rest.
➢ Should not drink alcohol for four hours prior to test
➢ No coffee or tea or smoking at least one hour before test
➢ Do not eat a large meal two hours prior to test
➢ No vigorous exercise 30 minutes before test
➢ Do not wear tight form fitting clothes
➢ May need to remove loose dentures for test
➢ Bring a list of all medications – potentially withhold bronchodilators,
corticosteroids
➢ Withholding bronchodilators preparations (see next slide)
➢ Empty the bladder in females or those with history of urinary incontinence
immediately before the test .
Basics, Current Recommendations & interpretation of PFT
Guidelines for withholding medical preparations
Medications may be continued if the PFT aims to assess the patient condition on
treatment (controlled or not)
B2 agonists

• Inhaled short-acting B2 agonist (SABA) 4-8 hours

• Inhaled long-acting B2 agonist (LABA) 24 hours

• Oral short-acting B2 agonist (SABA) 8 hours

• Oral long-acting B2 agonist (LABA) 24 hours

Anticholinergic

• Inhaled short-acting anticholinergic 6-8 hours

• Inhaled long-acting anticholinergic 24 hours

Theophylline

• Twice daily preparation 24 hours

• Once daily preparations 48 hours

Corticosteroids

• Short-acting inhaled corticosteroids (ICS) 8 hours

• Long-acting inhaled corticosteroids (ICS) 24 hours

• Oral short acting corticosteroids 24 hours

• Oral corticosteroids 48 hours
These Combined inhalers (Anora® (umeclidinium and vilanterol); Bevespi® (glycopyrrolate and formoterol); 48 hours
Stiolto® (olodaterol and tiotropium); Utibron® (indacaterol and glycopyrrolate); Trelegy® (fluticasone,
umeclidinium and vilanterol)
Spirometry technique … 1 (Test Preparation )

o Revise indications, contraindications, physician’ instructions, patient responds well to

instructions
o Information about the purpose: before starting, explain to the pt. How fast & how
much he can exhale from his lungs.
o Ask patient to remove any gum – candy – dentures and loosen restrictive clothing
o patient may sit or stand during testing but consistent and record the position
o Tell the pt. That only the maximal effort will lead to a reliable result. This may enhance
his motivation to follow the instructions correctly.
o Demonstrating of breathing maneuver: possible even without spirometer. this can save
a lot of time spent on repeated measurements. Explain the procedure using your own
mouthpiece, showing how deeply you need to inhale, how to correctly place the
mouthpiece into your moth (teeth on the outside with lips sealed tightly), and how fast
and long you need to exhale
o Have patient seated comfortably with upright position of head
o Closed-circuit technique
➢ Place nose clip on lower part of nose
➢ Have patient breathe on mouthpiece (notice mouth sealed around mouth piece)
➢ Mouthpiece between teeth [Lips tightly sealed ,Corners of the mouth closed]
➢ Teeth should slightly bite on the mouthpiece
➢ Tongue underneath mouthpiece
Spirometry technique … 2 (Test performance)

o Ask patient take a deep breath as fast as possible.

o Ask patient to Blow out as hard as they can until you tell them to stop
o Spirometry requires a voluntary maneuver in which a seated patient inhales maximally from
tidal respiration to total lung capacity and then rapidly exhales to the fullest extent until no
further volume is exhaled at residual volume
o couch patient. When spirometer is ready to go . Tell the subject to take aa deep a breath
possible before putting the mouthpiece into their mouth , now place their mouth on the
mouth piece , and Blast out the air , GO,GO,GO , Keep going until the subject has exhaled
for at least six second (3 second in children).
o Watch patient’s performance closely for poor maneuvers . If the effort appears
unacceptable, identify the reasons and instruct the pt. how to perform the test better
o Try to get the acceptable maneuvers , if after 8 attempts you are unsuccessful terminate
testing and reschedule for another day
o Print and review your spirometry results.
➢ Review acceptability criteria
➢ Review the results
➢ Write the interpretation
o Documentation
Spirometry technique: when to end test

Valid end-of-test
A. Smooth curvilinear rise of the volume-time tracing to a plateau
of at least 1-second duration;
B. If a test fails to exhibit an expiratory plateau, a forced expiratory
time (FET) of 15 seconds; or
C. When the patient cannot or should not continue forced
exhalation for valid medical reasons.

If both of these criteria are not met, continue testing until: Both of
the criteria are met with analysis of additional acceptable spirograms
or
A total of eight tests have been performed or
Save a minimum of three best maneuvers
 Spirometry technique: positioning
Test position: The test position should be noted on the report
Seating Position
➢The standing position is not advised, because most reference equations refer to the seating
position.
➢Besides, in case of dizziness during the forced exhalation, seating helps to maintain the balance.

Upright position
➢It is important to instruct the patient to sit erect, because the lungs need abdominal space
to reach maximal volume.
➢Instruct the subject to loosen tight clothing that may interfere with maximal inspiration.

Position of the head

➢Straight or in slight extension
➢Flexion or rotation of the head increase upper airway resistance
➢Instruct the patient to elevate the chin slightly and to keep his head upright or slightly leaned
back. If the neck is flexed forward the upper airways are narrowing.

Handheld-spirometers
➢Keep an eye on the head position; patients tend to bow their head forward during expiration.
➢Look out!
• Flexion at forced manoeuvre
• Support arm recommended
➢Correct position of mouthpiece and nose clip
 Spirometry technique: Recommendations for better results
➢Patient should be examined relaxed and free of stress. Minimum 15 min. rest before the test
➢The measurement should be done in the sitting position with correct position of head and body.
➢Make a record of the patient’s sex, age and height and sometimes race.
➢Parameters measured in standing position are not better than in sitting position but different; parameter
values in standing position are 2-7% increased
➢Measurement should only be monitored and not yet recorded until the patient is regular breathing! No
hurry!
➢Instructions about maintaining a good seal around the mouthpiece can help reduce leaks. The correct
sealing of the lips can be inspected only visually! In the course of the measurement several times
checking.
➢The maximum inhalation to TLC, which is IVC, should be performed not only to the maximum
inspiratory volume but also with maximal speed and effort.
➢For maximal inhalation the patient needs on average 2 to 4 seconds. If the inspiratory time is increased,
most flows of the following forced exhalation are diminished.
➢The patient should be assured, that repeating the test is required and does not reflect a problem of their
part.
➢Clinical interpretation always in the combination of parameters and graphical appearance of
flow/volume loop (v.v.imp).
➢Values can be compared with predicted normal values.
 Basics, Current Recommendations & interpretation of PFT
Breathing manoeuvres
Forced spirometry with flow/volume-curve

➢From tidal breathing a slow and maximal exhalation has to be performed. After reaching the point of maximal
exhalation (no.1) the patient inspires fast and maximal (no.1, 2, 3) on instruction.
➢Immediately after reaching maximal inspiration (no.3) the patient should blast out suddenly with maximal effort; time of
exhalation 6 (4) seconds or there is no change in volume any more (no.3, 4, 5 right hand)
➢After every trial… pause of 30 - 40 seconds for recovery

• The maneuver may be performed in a forceful manner to generate (FVC) or in a more relaxed manner
to generate a slow vital capacity (SVC).
Spitometry technique: reporting

The result of Spirometry

1. The report should contain at least the following topics; Numeric values and % predicted : FVC, FEV1, FEF 25-75,
PEF
2. Flow-Volume curves of all acceptable trials (this enables the reader to assess the quality)
Acceptability & reproducibility criteria or standards
1. No coughing
2. Good start of test without hesitation: <5% of FVC exhaled prior to a max expiratory effort. (<5% extrapolation)
3. Lack of artifacts
4. No early termination of expiration: exhalation time of six seconds of smooth continuous exhalationor a plateau of
2 seconds
5. No variable flows: flow rate should be consistent and as fast as possible throughout exhaled VC
6. Good reproducibility or consistency of efforts: 2 best FVC's and 2 best FEV1's should agree within 5% or 100 ml
(whichever is greatest) (see next slide)
✓The measurements should not differ more than 5% or 200 ml. At least two measurements that meet the criteria for
acceptability should be performed
✓Maneuvers that are done with submaximal effort have a bigger variation than those with maximal effort. Therefore
maximal effort can be recognized in the reproducibility of these two measurements.
✓If the two measured FEV1 values doesn’t differ more than 5% or 200ml, the exam. is completed successfully. The
highest value is then reported as result.
✓The same applies to FVC. If the difference is more than 200 ml and 5%, new measurements must be done, until the
two best results agree with the required precision
Spirometry technique: validation

• After three acceptable spirograms have been obtained, apply the

following tests.
✓ Are the two largest FVCs within 0.2 L of each other?
✓ Are the two largest FEV1s within 0.2 L of each other?
✓ In other words
➢Largest FVC within 200 ml of next largest FVC
➢Largest FEV1 within 200 ml of next largest FEV1
➢If the two above not met, additional spirogram should be
obtained
 Spirometry validation
Check of the manoeuvres for errors
➢The patient can be assured the correct breathing or the assistant can make suggestions for
improvement.
➢Not more than 6 forced manoeuvres should be necessary.
➢Pts with severe obstruction can have exhalation phases longer than 6 sec. The assistant should not
terminate the trial too early.
➢ATS criteria for quality in spirometry

Summary of errors in spirometry Problems caused by the patient

1.Insufficient cooperation or motivation
2.Assistant related failures
3.Wrong preparation of measurement
4.Incomplete or wrong instructions before start of measurement
5.Unmotivated assistant
6.Coughing or multiple breaths
Slow and forced vital capacity

❑ The slow vital capacity (SVC) can also be measured with

spirometers collect data for at least 30 seconds when airways
obstruction is present, the forced vital capacity (FVC) is reduced
and slow vital capacity (SVC) may be normal

❑ When the slow or forced vital capacity is within the normal range:
❖ No significant restrictive disorder .
❖ No need to measure static lung volumes (residual volume and total lung
capacity).
❖ The maneuver may be performed in a forceful manner to generate a forced
vital capacity (FVC) or in a more relaxed manner to generate a slow vital
capacity (SVC).
❖ In normal persons, the inspiratory vital capacity, the expiratory SVC, and
expiratory FVC are essentially equal. However, in patients with
obstructive airways disease, the expiratory SVC is generally higher than
the FVC.
 Useful Videos

https://www.youtube.com/watch?v=629HPu8C2Gs
https://www.youtube.com/watch?v=Zs8Fs5HaJHs
https://www.youtube.com/watch?v=Xeps-PD0r8g
https://www.youtube.com/watch?v=teqX9U2BzYc
https://www.youtube.com/watch?v=v6pW9FWz8RM
 Assignment

From your understanding suggest a preparation sheet to be

given to patient before performing spirometry
(individual)
The sheet better be in Arabic/English or in understandable
language

Each group should discuss with each other and have a final
version of the instructions

So you have to submit your personal version and each

group should submit final version