Making Sense of Lung Function Tests 2nd Edition

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MAKING SENSE of
Lung Function Tests
Second edition
A hands-on guide

Jonathan Dakin, MD FRCP BSc Hons

Consultant Respiratory Physician
Royal Surrey County Hospital NHS Foundation Trust
Surrey, UK
Honorary Consultant Respiratory Physician
Portsmouth Hospitals NHS Trust
Hampshire, UK

Mark Mottershaw, BSc Hons MSc

Chief Respiratory Physiologist
Queen Alexandra Hospital
Portsmouth Hospitals NHS Trust
Hampshire, UK

Elena Kourteli, FRCA

Consultant Anaesthetist
St George’s University Hospitals Foundation NHS Trust
London, UK
CRC Press
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Ὁ μεν βίος βραχὺς, ἡ δὲ τέχνη μακρὴ, ὁ δὲ καιρὸς ὀξὺς, ἡ δὲ πεῖρα σφαλερὴ,
ἡ δὲ κρίσις χαλεπή.

Ἱπποκράτης

Life is short, science is long; opportunity is elusive, experiment is dangerous,

judgement is difficult.

Hippocrates
Contents

Preface xv
Acknowledgement xv
Abbreviations xvii

1 Expressions of normality 1

PART 1 TESTS OF AIRWAY FUNCTION AND MECHANICAL

PROPERTIES 5

2 Peak expiratory flow 7

Introduction 7
Test description and technique 7
Pitfalls 7
Physiology of test 8
Normal values 8
Peak flow variability in the diagnosis of asthma 8
Assessment and management of asthma 11
Pitfall 12
3 Spirometry and the flow–volume loop 13
Introduction 13
Measured indices and key definitions 13
Test description and technique 13
Physiology of tests 16
Restrictive and obstructive defects 16
Restrictive defects 16
Obstructive defects 18
Maximum expiratory flows 18
Normal values 20
Assessment of severity of obstruction 21
Mid-expiratory flows 22

vii
viii Contents

FVC versus VC 23
Patterns of abnormality 23
Obstructive spirometry 23
Restrictive spirometry 25
Reduction of FEV1 and FVC 27
Mixed obstructive/restrictive defect 27
Non-specific ventilatory defect 28
Large airways obstruction 29
Fixed upper airway obstruction 29
Variable extrathoracic obstruction 29
Variable intrathoracic obstruction 31
Clinical pearls 31
4 Airway responsiveness 35
Introduction 35
Test physiology 35
Test descriptions 36
Reversibility 36
Challenge testing 37
Interpretation of results 37
Reversibility 37
Challenge testing 38
5 Fractional concentration of expired nitric oxide 41
Introduction 41
Test description/technique 41
Physiology of test 42
Normal values and interpretation 43
Specific considerations 44
6 Gas transfer 45
Introduction 45
Measured indices/key definitions 45
Alveolar volume 46
K CO 46
Test description 47
Physiology of gas exchange 48
Normal values 48
Patterns of abnormality 49
Incomplete lung expansion 49
Discrete loss of lung units 51
Diffuse loss of lung units 52
 Contents ix

Pulmonary emphysema 52
Pulmonary vascular disease 53
Causes of increased gas transfer 54
Clinical pearls 54
Interstitial lung disease 54
Obstructive disease 55
Acute disease 56
7 Static lung volumes and lung volume subdivisions 57
Introduction 57
Measured indices/key definitions 57
Test descriptions/techniques 59
Helium dilution 59
Nitrogen washout 61
Whole-body plethysmography 61
Comparison of methods 63
Physiology of lung volumes 64
Total lung capacity 64
Residual volume 64
Functional residual capacity 64
Closing capacity 65
Normal values 65
Patterns of abnormality 66
Relationship between VC and TLC 67
Obstructive lung disease 67
Interstitial lung disease 67
Miscellaneous 68
Specific considerations 68
Anaesthesia 68
FRC in patients receiving ventilatory support: PEEP
and CPAP 68
Clinical pearls 70
8 Airway resistance 73
Introduction 73
Physiology of airway resistance tests 74
Plethysmography technique 75
Test description/technique 75
Measured indices/key definitions 76
Normal values 76
Patterns of abnormality 76
x Contents

Oscillometry techniques 79
Test description/technique 79
Measured indices/key definitions 79
Normal values 82
Patterns of abnormality 82
Assessment of severity 84
Specific and clinical considerations 84
9 Respiratory muscle strength 87
Introduction 87
Test descriptions/techniques 87
Upright and supine vital capacity 87
Static lung volumes 90
Maximal expiratory pressure 90
Maximal inspiratory pressure 90
Sniff nasal inspiratory pressure 90
Sniff trans-diaphragmatic pressure 91
Direct electromagnetic phrenic nerve stimulation 91
Cough peak flow 91
Arterial blood gases 92
Radiological assessment of muscle strength 92
Clinical interpretation of tests of muscle strength 93
Forced vital capacity 93
Sniff nasal inspiratory pressure 94
MIP and MEP 94
The twitch PDI 95
Sleep, ventilatory failure, and VC 95
Clinical pearls 99

PART 2 BLOOD GAS INTERPRETATION 103

10 Assessment of ventilation 105

Introduction 105
Measured indices/key definitions 105
Physiology of ventilation in relation to CO2 105
Normal values 108
Measurement of venous blood gases 109
Causes of hypercapnia 109
Chronic obstructive pulmonary disease 110
Obesity hypoventilation syndrome 111
 Contents xi

Exhaustion 111
Increased CO2 production 112
Causes of low PCO2 112
Hypoxaemia 112
Metabolic acidosis 112
Central nervous system disorders 112
Drugs 112
Anxiety 113
Clinical pearls 113
11 Assessment of haemoglobin saturation 115
Introduction 115
Measured indices 115
Measurement of oxygen saturation 116
Pulse oximetry 117
Waveform 117
Accuracy 118
Specific sources of error 119
Pros and cons of pulse oximetry 120
Physiology – oxygen dissociation curve 120
What determines the amount of oxygen carried in
blood? 121
Normal values 122
Carbon monoxide poisoning 122
Clinical pearls 123
12 Assessment of oxygenation 125
Introduction 125
Normal values 125
Measurement of PaO2 125
Measurement of arterialised capillary PO2 126
The oxygen cascade 127
Humidification of dry air 128
Alveolar gas 128
Arterial blood 129
A–a partial pressure PO2 difference 129
Tissue 132
Relationship between alveolar PO2 and arterial PCO2 132
Clinical pearls 133
Specific clinical considerations 133
Hypoxaemia 133
xii Contents

Apnoeic respiration 134

Chronic respiratory failure 135
13 Assessment of acid–base balance 137
Introduction 137
Measured indices/key definitions 137
Physiology of acid–base balance 138
Compensation 139
Classification of acid–base disorders 140
Respiratory disorder 140
Metabolic disorder 140
Evaluating compensation of acid–base disturbance 141
Respiratory compensation for metabolic disorder 142
Metabolic compensation for respiratory disorder 142
Time course of compensation 143
Summary: Evaluation of acid–base disorders 143

PART 3 EXERCISE TESTING 145

14 Field exercise tests 147

Introduction 147
Measurement indices 147
Description of tests 148
Six-minute walk test 148
Incremental shuttle walk test 149
Endurance shuttle walk test 149
Choice of field-walking test 149
Physiology of field exercise tests 150
Normal values 151
Six-minute walk test 151
Incremental shuttle walk test 151
Endurance shuttle walk test 151
Clinical pearls 152
15 Cardiopulmonary exercise testing 155
Introduction 155
Measured indices/key definitions 155
Test description/technique 155
Physiology of exercise testing 159
Normal physiological responses 159
Normal values 164
 Contents xiii

Patterns of abnormality 165

Exercise tolerance 165
Lung disease 165
Heart disease – ischaemic heart disease 166
Heart disease – cardiomyopathy 168
Pulmonary vascular disease 168
Summary 169
Assessment of severity 169
Specific considerations 171

PART 4 INTERPRETATION 173

16 A strategy for interpretation of pulmonary function tests 175

Introduction 175
17 Characteristic pulmonary function abnormalities 183
Airway diseases 183
Asthma 183
Chronic obstructive pulmonary disease 183
Bronchiolitis 184
Bronchiectasis 184
Large airway obstruction – variable extrathoracic 184
Large airway obstruction – variable intrathoracic 184
Fixed upper airway obstruction 185
Restrictive diseases interstitial lung disease 185
Pleural disease 185
Chest wall deformity 186
Muscle weakness 186
Post-pulmonary resection surgery 186
Pulmonary vascular disease 187
Pulmonary arterial hypertension 187
Recurrent pulmonary emboli 187
Chronic pulmonary venous congestion 187
Carbon monoxide poisoning 187
References 189
Index 197
Preface

Every doctor involved in acute medicine deals with blood gas or lung func-
tion data. Although a wealth of information lies therein, much of the content
may be lost on the non-specialist. Frequently the information necessary for
interpretation of basic data is buried deep in heavy specialist texts. This book
sets out to unearth these gems and present them in a context and format use-
ful to the frontline doctor. We accompany the clinical content with underly-
ing physiology because we believe that for a little effort it offers worthwhile
enlightenment. However, as life in clinical medicine is busy, we have placed
the physiology in separate sections, so that those who want to get to the bot-
tom line first can do so.
This book is not a technical manual, and details of performing laboratory
test are kept to minimum to outline the physical requirements for success-
ful compliance. Nor is it a reference manual for the specialist. The aim is to
present information in an accessible way, suitable for those seeking a basic
grounding in spirometry or blood gases, but also sufficiently comprehensive
for readers completing specialist training in general or respiratory medicine.

ACKNOWLEDGEMENT
We wish to thank Warwick Hampden-Woodfall for essential IT backup.

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