PULMONARY FUNCTION

TESTS

[email protected]

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 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.

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 Lung Volumes
• Tidal Volume (TV): volume of air
inhaled or exhaled with each
breath during quiet breathing (6-
8 ml/kg)
• Inspiratory Reserve Volume
(IRV): maximum volume of air
inhaled from the end-inspiratory
tidal position.(1900-3300ml)
• Expiratory Reserve Volume
(ERV): maximum volume of air
that can be exhaled from resting
end-expiratory tidal position.
( 700-1000ml).

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 Lung Volumes

• Residual Volume (RV):

– Volume of air remaining
in lungs after maximium
exhalation (20-25 ml/kg)
(1700-2100ml)
– Indirectly measured
(FRC-ERV)
– It can not be measured
by spirometry

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 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) (3100-4800ml)
• 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

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 Lung Capacities (cont.)
• 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) (2300-3300ml).
– Measured with multiple-
breath closed-circuit helium
dilution, multiple-breath
open-circuit nitrogen
washout, or body
plethysmography.
– It can not be measured by
spirometry)

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 VOLUMES, CAPACITIES AND THEIR
CLINICAL SIGNIFICANCE
1) TIDAL VOLUME (TV):
 VOLUME OF AIR INHALED/EXHALED IN EACH BREATH
DURING QUIET RESPIRATION.
 N – 6-8 ml/kg.
 TV FALLS WITH DECREASE IN COMPLIANCE, DECREASED
VENTILATORY MUSCLE STRENGTH.

2) INSPIRATORY RESERVE VOLUME (IRV):

 MAX. VOL. OF AIR WHICH CAN BE INSPIRED AFTER A
NORMAL TIDAL INSPIRATION i.e. FROM END INSPIRATION
PT.
 N- 1900 ml- 3300 ml.
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 CONTINUED………
3) EXPIRATORY RESERVE VOLUME (ERV):
 MAX. VOLUME OF AIR WHICH CAN BE EXPIRED AFTER A
NORMAL TIDAL EXPIRATION i.e. FROM END EXPIRATION
PT.
 N- 700 ml – 1000 ml
4) INSPIRATORY CAPACITY (IC) :
 MAX. VOL. OF AIR WHICH CAN BE INSPIRED AFTER A
NORMAL TIDAL EXPIRATION.
 IC = IRV + TV
 N-2400 ml – 3800 ml.

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 CONTINUED………..
4) VITAL CAPACITY: COINED BY JOHN
HUTCHINSON.
 MAX. VOL. OF AIR EXPIRED AFTER A MAX.
INSPIRATION .
 MEASURED WITH VITALOGRAPH
 VC= TV+ERV+IRV
 N- 3.1-4.8L. OR 60-70 ml/kg
 VC IS COSIDERED ABNORMAL IF ≤ 80% OF
PREDICTED VALUE

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 FACTORS INFLUENCING VC
• PHYSIOLOGICAL :
 physical dimensions- directly proportional to ht.
 SEX – more in males : large chest size, more
muscle power, more BSA.
 AGE – decreases with increasing age
 STRENGTH OF RESPIRATORY MUSCLES
 POSTURE – decreases in supine position
 PREGNANCY- unchanged or increases by 10%
( increase in AP diameter In pregnancy)

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 CONTINUED………
• PATHOLOGICAL:
 DISEASE OF RESPIRATORY MUSCLES
 ABDOMINAL CONDITION : pain, dis. and
splinting

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 FACTORS DECREASING VITAL
CAPACITY
1) Alteration in muscle power- d/t drugs, n-m
dis., cerebral tumours.
2) Pulmonary diseases – pneumonia, chronic
bronchitis, asthma, fibrosis, emphysema,
pulmonary edema,.
3) Space occupying lesions in chest- tumours,
pleural/pericardial effusion, kyphoscoliosis
4) Abdominal tumours, ascites.

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5) Depression of respiration : opioids/ volatile
agents
6) Abdominal splinting – abdominal binders,
tight bandages, hip spica.
7)Abdominal pain – decreases by 50% & 75% in
lower & upper abdominal Surgeries
respectively.
8) Posture – by altering pulmonary Blood
volume.
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 DIFFERENT POSTURES AFFECTING VC
• POSITION • DECREASE IN VC
 TRENDELENBERG  14.5%
 LITHOTOMY  18%
 PRONE  10%
 RT. LATERAL  12%
 LT. LATERAL  10%

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 VC CONTINUED…….
• VC correlates with capability for deep
breathing and effective cough.

• So in post operative period if VC falls below 3

times VC– artificial respiration is needed to
maintain airway clear of secretions.

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 CONTINUED…….
6) TOTAL LUNG CAPACITY :
 Maximum volume of air attained in lungs after
maximal inspiration.
 N- 4-6 l or 80-100 ml/kg
 TLC= VC + RV
7) RESIDUAL VOLUME (RV):
 Volume of air remaining in the lungs after
maximal expiration.
 N- 1570 – 2100 ml OR 20 – 25 ml/kg.

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 CONTINUED……
8) FUNCTIONAL RESIDUAL CAPACITY (FRC):
 Volume of air remaining in the lungs after
normal tidal expiration, when there is no airflow.
 N- 2.3 -3.3 L OR 30-35 ml/kg.
 FRC = RV + ERV
 Decreases under anaesthesia
• with spontaneous Respiration – decreases by
20%
• With paralysis – decreases by 16%

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 FACTORS AFFECTING FRC
• FRC INCREASES WITH
• Increased height
• Erect position (30% more than in supine)
• Decreased lung recoil (e.g. emphysema)
• FRC DECREASES WITH
• Obesity
• Muscle paralysis (especially in supine)
• Supine position
• Restrictive lung disease (e.g. fibrosis, Pregnancy)
• Anaesthesia
• FRC does NOT change with age.

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 FUNCTIONS OF FRC
• Oxygen store
• Buffer for maintaining a steady arterial po2
• Partial inflation helps prevent atelectasis
• Minimise the work of breathing
• Minimise pulmonary vascular resistance
• Minimised v/q mismatch
- only if closing capacity is less than frc
• Keep airway resistance low (but not minimal

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 Pulmonary Function Tests

• The term encompasses a wide variety of

objective tests to assess lung function

• Provide objective and standardized

measurements for assessing the presence and
severity of respiratory dysfunction.

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 GOALS
 To predict the presence of pulmonary
dysfunction
 To know the functional nature of disease
(obstructive or restrictive. )
 To assess the severity of disease
 To assess the progression of disease
 To assess the response to treatment
 To identify patients at increased risk of morbidity
and mortality, undergoing pulmonary resection.

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 GOALS, CONTINUED……..

 To wean patient from ventilator in icu.

 Medicolegal- to assess lung impairment as a
result of occupational hazard.
 Epidemiological surveys- to assess the
hazards to document incidence of disease
 To identify patients at perioperative risk of
pulmonary complications

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 INDICATIONS OF PFT IN PAC

TISI GUIDELINES FOR PREOPERATIVE

SPIROMETRY
 Age > 70 yrs.
 Morbid obesity
 Thoracic surgery
 Upper abdominal surgery
 Smoking history and cough
 Any pulomonary disease

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 INDICATIONS FOR PREOPERATIVE
SPIROMETRY
• ACP GUIDELINES FOR PREOPERATIVE
SPIROMETRY
 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)

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 BED SIDE PFT
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

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 BED SIDE PFT
2) Single breath count:
After deep breath, hold it and start counting till the
next breath.
 N- 30-40 COUNT
 Indicates vital capacity

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 BED SIDE PFT
3) 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
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 BED SIDE PFT
• 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.
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 BED SIDE TEST
4) 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.
VC ~ 3 TIMES TV FOR EFFECTIVE COUGH.

A wet productive cough / self propagated paraoxysms of

coughing – patient susceptible for pulmonary Complication.

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 BED SIDE TEST
5) 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

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 BED SIDE PFT

6) 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.
7) DEBONO 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.

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 MEASUREMENT OF TV & MV
8)Wright respirometer : measures tv, mv (15 secs times 4)

• Simple and rapid

• Instrument- compact, light and portable.
• Disadvantage: It under- reads at low flow rates and over- reads at high
flow rates.
• Can be connected to endotracheal tube or face mask
• Prior explanation to patients needed.
• Ideally done in sitting pos.
• MV- instrument record for 1 min. And read directly
• TV-calculated and dividing MV by counting Respiratory Rate.

• USES: 1)BED SIDE PFT

• 2) ICU – WEANIG PTS. FROM Ventilation .

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DEBONO’S WHISTLE

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 BED SIDE PFT
9) MICROSPIROMETERS – MEASURE VC.

10) BED SIDE PULSE OXIMETRY

11) ABG.

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 CATEGORIZATION OF PFT
1) MECHANICAL VENTILATORY FUNCTIONS OF
LUNG / CHEST WALL:
A) STATIC LUNG VOLUMES & CAPACITIES – VC, IC, IRV,
ERV, RV, FRC.
B) DYNAMIC LUNG VOLUMES –FVC, FEV1, FEF 25-75%,
PEFR, MVV, RESP. MUSCLE STRENGTH
C) VENTILATION TESTS – TV, MV, RR.

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 CATEGORIZATION OF PFT
2) GAS- EXCHANGE TESTS:
A) Alveolar-arterial po2 gradient
B) Diffusion capacity
C) Gas distribution tests- single breath
N2 test.
- Multiple Breath N2 test
- Helium dilution method.
- Radio Xe scinitigram.
D) ventilation – perfusion tests
A) ABG
B) single breath CO2 elimination test
C) Shunt equation

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 CATEGORIZATION OF PFT
3) CARDIOPULMONARY INTERACTION:
A) Qualitative tests:
- History , examination
- Abg
- Stair climbing test

B) Quantitative tests
- 6 min. Walk test (gold standard)

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 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.”
• Measures VC, FVC, FEV1, PEFR.
• CAN’T MEASURE – FRC, RV, TLC.
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 PREREQUISITIES
• Prior explanation to the patient
• Not to smoke /inhale bronchodilators 6 hrs
prior or oral bronchodilators 12hrs prior.
• Remove any tight clothings/ waist belt/
dentures
• Pt. Seated comfortably
If obese, child < 12 yrs- standing

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 PREREQUISITES
• Nose clip to close nostrils.
• Exp. Effort shld last ≥ 4 secs.
• Should not be interfered by coughing, glottic
closure, mechanical obstruction.
• 3 acceptable tracings taken & largest value is
used.

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 SPIROMETER
• Double walled cylinder with water to maintain
water tight seal
• Inverted bell (9 l) attached to pulley which
carries a counterweight and pen – moves up
and down as volume of bell changes
• BREATHING ASSEMBLY i.E. Unidirectional
breathing valves with mouth piece.

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 Flow-Volume Curves and Spirograms

• Two ways to record results of FVC maneuver:

– Flow-volume curve---flow meter measures flow

rate in L/s upon exhalation; flow plotted as
function of volume

– Classic spirogram---volume as a function of time

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Normal Flow-Volume Curve and
Spirogram

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 Spirometry Interpretation: So what
constitutes normal?
• Normal values vary and depend on:
– Height
– Age
– Gender
– Ethnicity

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Acceptable and Unacceptable
Spirograms (from ATS, 1994)

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 Measurements Obtained from the FVC
Curve
• FEV1---the volume exhaled during the first second of the FVC
maneuver

• FEF 25-75%---the mean expiratory flow during the middle half

of the FVC maneuver; reflects flow through the small (<2 mm
in diameter) airways

• FEV1/FVC---the ratio of FEV1 to FVC X 100 (expressed as a

percent); an important value because a reduction of this ratio
from expected values is specific for obstructive rather than
restrictive diseases

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 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
• Obstructive Disorders • Restrictive Disorders
– Characterized by a limitation – Characterized by reduced
of expiratory airflow so that lung volumes/decreased lung
airways cannot empty as compliance
rapidly compared to normal Examples:
(such as through narrowed – Interstitial Fibrosis
airways from bronchospasm,
inflammation, etc.) – Scoliosis
Examples: – Obesity
– Asthma – Lung Resection
– Emphysema – Neuromuscular diseases
– Cystic Fibrosis – Cystic Fibrosis

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Normal vs. Obstructive vs. Restrictive

(Hyatt,
2003)
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 Spirometry Interpretation: Obstructive vs.
Restrictive Defect
• Obstructive Disorders • Restrictive Disorders
– FVC nl or↓ – FVC ↓
– FEV1 ↓ – FEV1 ↓
– FEF25-75% ↓ – FEF 25-75% nl to ↓
– FEV1/FVC ↓ – FEV1/FVC nl to ↑
– TLC nl or ↑ – TLC ↓

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 Spirometry Interpretation: What do the
numbers mean?
• FVC FEV1
• Interpretation of % Interpretation of % predicted:
predicted: – >75% Normal
– 80-120% Normal – 60%-75% Mild obstruction
– 70-79% Mild reduction – 50-59% Moderate
– 50%-69% Moderate reduction obstruction
– <50% Severe reduction – <49% Severe obstruction
• <25 y.o. add 5% and >60 y.o.
subtract 5

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 Spirometry Interpretation: What do the
numbers mean?
• FEF 25-75% • FEV1/FVC
• Interpretation of % • Interpretation of
predicted: absolute value:
– >79% Normal – 80 or higher
– 60-79% Mild Normal
obstruction – 79 or lower
– 40-59% Moderate Abnormal
obstruction
– <40% Severe obstruction

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What about lung volumes and obstructive
and restrictive disease?

(From Ruppel,
2003)

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 MEASUREMENTS OF VOLUMES
• TLC, RV, FRC – MEASURED USING
 Nitrogen washout method
 Inert gas (helium) dilution method
 Total body plethysmography

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 CONTINUED………..
1) HELIUM DILUTION METHOD:
Patient breathes in and out of a spirometer filled with 10%
helium and 90% o2, till conc. In spirometer and lung
becomes same (equilibirium).
As no helium is lost; (as he is insoluble in blood)
C1 X V1 = C2 ( V1 + V2)
V2 = V1 ( C1 – C2)
C2
V1= VOL. OF SPIROMETER
V2= FRC
C1= Conc.of He in the spirometer before equilibrium
C2 = Conc, of He in the spirometer after equilibrium
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 CONTINUED………
2) TOTAL BODY PLETHYSMOGRAPHY:
Subject sits in an air tight box. At the end of normal exhalation – shuttle of
mouthpiece closed and pt. is asked to make resp. efforts. As subject inhales
– expands gas volume in the lung so lung vol. increases and box pressure
rises and box vol. decreases.
BOYLE’S LAW:
PV = CONSTANT (at constant temp.)
For Box – p1v1 = p2 (v1- ∆v)
For Subject – p3 x v2 =p4 (v2 - ∆v)
P1- initial box pr. P2- final box pr.
V1- initial box vol. ∆ v- change in box vol.
P3- initial mouth pr., p4- final mouth pr.
V2- FRC
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 CONTINUED………
DIFFERENCE BETWEEN THE TWO METHODS:
• In healthy people there is very little difference.
• Gas dilution technique measures only the
communicating gas volume.
• Thus,
• Gas trapped behind closed airways
• Gas in pneumothorax
• => are not measured by gas dilution technique,
but measured by body plethysmograph

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 CONTINUED………
3) N2 WASH OUT METHOD:
• Following a maximal expiration (RV) or normal expiration (FRC), Pt.
inspires 100% O2 and then expires it into spirometer ( free of N2)
→ over next few minutes (usually 6-7 min.), till all the N2 is washed
out of the lungs. N2 conc. of spirometer is calculated followed by
total vol.of AIR exhaled. As air has 80% N2 → so actual FRC/RV is
calculated.
• E.g. Total vol. collected = 50 L (as N2 makes 80% of FRC on
• room air)
• Measured N2 = 5%
• vol. of N2 in bag = 50 x .05 = 2.5L
• 2.5 L = X L
• .80 FRC 1 FRC
• X = 3.125 l (THIS IS PT’S FRC)

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 PROBLEMS WITH N2 WASH OUT
METHOD
• Atelectasis may result from washout of
nitrogen from poorly ventilated lung zones
(obstructed areas)
• Elimination of hypoxic drive in CO2 retainers
is possible
• Underestimates FRC due to underventilation
of areas with trapped gas

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 MEASUREMENT OF DYNAMIC LUNG
VOLUMES FEF25–75% = forced
expiratory flow during
• TIMED EXPIRED SPIROGRAMS expiration of 25 to 75%
of the FVC; FEV1 = forced
expiratory volume in the
first second of forced
vital capacity maneuver;
FVC = forced vital
capacity (the maximum
amount of air forcibly
expired after maximum
inspiration).

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 FORCED VITAL CAPACITY (FVC)
Max vol. Of air which can be expired out as forcefully and
rapidly as possible, following a maximal inspiration to
TLC.
 Exhaled volume is recorded with respect to time.
 Indirectly reflects flow resistance property of airways.
 Normal healthy subjects have VC = FVC.
 Prior instruction to patients, practice attempts as it
needs patient cooperation and effect.
 Exhalation should take at least 4 sec and should not be
interrupted by cough, glottic closure or mechanical
obstruction.

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 FORCED VITAL CAPACITY IN 1 SEC.
(FEV1)
 Forced expired vol. In 1 sec during fvc
maneuver.
 Expressed as an absolute value or % of fvc.
 N- FEV1 (1 SEC)- 75-85% OF FVC
 FEV2 (2 SEC)- 94% OF FVC
 FEV3 (3 SEC)- 97% OF FVC

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 CONTINUED……
CLINICAL RANGE (FEV1) PATIENT GROUP
• 3 - 4.5 L • NORMAL ADULT
• 1.5 – 2.5 L • MILD – MOD.OBSTRUCTION
• <1 L • HANDICAPPED
• 0.8 L • DISABILITY
• 0.5 L • SEVERE EMPHYSEMA

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 CONTINUED……
FEV1 – Decreased in both obstructive &
restrictive lung disorders.
FEV1/FVC – Reduced in obstructive disorders.
NORMAL VALUE IS 75 – 85 % (FEV1/FVC)
< 70% OF PREDICTED VALUE – MILD OBST.
< 60% OF PREDICTED VALUE – MODERATE OBST.
< 50% OF PREDICTED VALUE – SEVERE OBST.

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 CONTINUED……
DISEASE STATES FVC FEV1 FEV1/FVC

1) OBSTRUCTIVE NORMAL ↓ ↓

2) STIFF LUNGS ↓ ↓ NORMAL

3 ) RESP. MUSCLE ↓ ↓ NORMAL

WEAKNESS

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 PEAK EXPIRATORY FLOW RATE (PEFR)

- It is the max. Flow rate during fvc maneuver in the initial 0.1
sec.

-PEFR DETERMINED BY : 1) Function of caliber of airways

2) Expiratory muscle strength
3) Pt’s coordination & effort

- Estimated by 1) drawing a tangent to steepest part of FVC

spirogram (error prone)
2) average flow during the litre of gas expired after
initial 200 ml during fvc maneuver.
- .

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- Normal value in young adults (<40 yrs)= 500l/min
- Measured with pneumotachograph / Wright peak flow
meter
- Wright peak flow meter - valuable tool in identifying
gross pulmonary Disability at bedside.
-Less unpleasant & less
Exhaustive

- Clinical significance - values of <200/l- impaired

coughing & hence likelihood of post-op complication
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 FORCED MID-EXPIRATORY FLOW RATE
(FEF25%-75%):
• Maximum Mid expiratory Flow rate
• Max. Flow rate during the mid-expiratory part of FVC maneuver.
• Effort independent
• Misnomer, as FEF25-75% decreased by
1) marked reduction in exp. Effort
2)submaximal inspiration b4 maneuver → ↓FVC → ↓ FEF25-
75%
• It may decrease with truly max. Effort as compared to slightly
submaximal effort as dynamic airway compression occurs with
maximal effort.
• N value – 4.5-5 l/sec. Or 300 l/min.
• Upto 2l/sec- acceptable.
• CLINICAL SIGNIFICANCE: SENSITIVE & IST INDICATOR OF
OBSTRUCTION OF SMALL DISTAL AIRWAYS

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 MAXIMUM BREATHING CAPACITY:
(MBC/MVV)

• MAX. VOLUNTARY VENTILATION

 Largest volume that can be breathed per minute by voluntary
effort , as hard & as fast as possible.
 N – 150-175 l/min.
 Estimate of max. Ventilation available to meet increased
physiological demand.
 Measured for 12 secs – extrapolated for 1 min.
 MVV = FEV1 X 35

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 CONTINUED…….
• Discrepancy b/w FEV1 and MVV means inconsistent /
submaximal inspiratory effort
• MBC/MVV altered by- airway resistance
- Elastic property
-Muscle strength
- Learning
- Coordination
- Motivation

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RESPIRATORY MUSCLE STRENGTH
Evaluated by measuring max. Static resp. Pressure
with anaeroid gauge
• Pressures are generated against occluded airway
during a max. Forced insp/exp. Effort
MAX STATIC INSP. PRESSURE: (PIMAX)-
• Measured when inspiratory muscles are at their
optimal length i.e. at RV
• PI MAX = -125 CM H2O
• CLINICAL SIGNIFICANCE:
 IF PI MAX< 25 CM H2O – Inability to take deep breath.

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 CONTINUED…….
• MAX. STATIC EXPIRATORY PRESSURE (PEMAX):
 Measured after full inspiration to TLC
 N VALUE OF PEMAX IS =200 CM H20
 PEMAX < +40 CM H20 – Impaired cough ability
 Particularly useful in pts with NM Disorders during
weaning

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 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
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 Continued……
DISEASE MSL. STRENGTH Raw PL
N-M WEAKNESS ↓ N N

EMPHYSEMA N N ↓

ASTHMA/BRONCHI N ↑ N
TIS
PERIPHERAL N N N
AIRWAY DIS.

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 MEASUREMENT OF AIRWAY
RESISTANCE
1) Raw- Body plethysmography
2) Forced expiratory maneuvers:
 Peak expiratory flow (PEF)
 FEV1
3) Response to bronchodialtors (FEV1)

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 Spirometry Pre and Post Bronchodilator

• Obtain a flow-volume loop.

• Administer a bronchodilator.
• Obtain the flow-volume loop again a minimum of 15
minutes after administration of the bronchodilator.
• Calculate percent change (FEV1 most commonly
used---so % change FEV 1= [(FEV1 Post-FEV1
Pre)/FEV1 Pre] X 100).
• Reversibility is with 12% or greater change.

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 AIRWAY PARTITIONING AND
BEHAVIOUUR
• UPPER (EXTRATHORACIC)
 Surrounding soft tissue unsupporting
 Collapses during inspiration
 Expands during expiration
• INTRATHORACIC
 Outer surface exposed to pleural pressure
 Expands during inspiration
 Collapses during expiration
• DISTAL (PULMONARY)
 Intimately related to lung tissue
 Collapses as expiration proceeds

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 FLOW VOLUME LOOPS

• Do FVC maneuver and then inhale as rapidly

and as much as able.
• This makes an inspiratory curve.
• The expiratory and inspiratory flow volume
curves put together make a flow volume loop.

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Flow-Volume Loops

(Rudolph and
Rudolph, 2003)

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 How is a flow-volume loop helpful?
• Helpful in evaluation of air flow limitation on inspiration and
expiration

• In addition to obstructive and restrictive patterns, flow-

volume loops can show provide information on upper airway
obstruction:
– Fixed obstruction: constant airflow limitation on inspiration and
expiration—such as in tumor, tracheal stenosis
– Variable extrathoracic obstruction: limitation of inspiratory flow,
flattened inspiratory loop—such as in vocal cord dysfunction
– Variable intrathoracic obstruction: flattening of expiratory limb; as in
malignancy or tracheomalacia

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TESTS FOR GAS EXCHANGE FUNCTION
1) ALVEOLAR-ARTERIAL O2 TENSION GRADIENT:
 Sensitive indicator of detecting regional V/Q inequality
 N value in young adult at room air = 8 mmhg to upto
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)

PAO2 = PIO2 – PaCo2

R

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 CONTINUED……..
2) DYSPNEA DIFFENRENTIATION INDEX (DDI):
- To d/f dyspnea due to resp/ cardiac d’s

DDI = PEFR x PaCO2

1000
- DDI- Lower in resp. pathology

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 CONTINUED……
3) DIFFUSING CAPACITY OF LUNG: defined as the
rate at which gas enters into bld. divided by its
driving pr.
DRIVING PR: gradient b/w alveoli & end capillary
tensions.
Fick’s law of diffusion : Vgas = A x D x (P1-P2)
T
D= diffusion coeff= solubility
√MW

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 CONTINUED…….
• DL IS MEASURED BY USING CO, COZ:
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

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 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
• N range 20- 30 ml/min./mmhg.
• DLO2 = DLCO x 1.23
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DLCO decreases in-
• Emphysema, lung resection, pul. Embolism, anaemia
• Pulmonary fibrosis, sarcoidosis- increased thickness
• DLCO increases in:
(Cond. Which increase pulm, bld flow)
 Supine position
 Exercise
 Obesity
 L-R shunt

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 TESTS FOR CARDIOPLULMONARY
INTERACTIONS
• Reflects gas exchange, ventilation, tissue O2,
CO.
• QUALITATIVE- history, exam, ABG, stair
climbing test
• QUANTITATIVE- 6 minute walk test

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 CONTINUED…….
• 1) STAIR CLIMBING TEST:
• If able to climb 3 flights of stairs without stopping/dypnoea at
his/her own pace- ↓ed morbidity & mortality
• If not able to climb 2 flights – high risk
• 2) 6 MINUTE WALK TEST:
- Gold standard
- C.P. reserve is measured by estimating max. O2 uptake during
exercise
- Modified if pt. can’t walk – bicycle/ arm exercises
- If pt. is able to walk for >2000 feet during 6 min pd,
- VO2 max > 15 ml/kg/min
- If 1080 feet in 1 min : VO2 of 12ml/kg/min
- Simultaneously oximetry is done & if Spo2 falls >4%- high risk

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 EVALUATION OF PT. FOR LUNG
RESECTION
GOALS:
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.

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 CONTINUED…..
• Removal of entire lung is likely to be tolerated
if pre-op pulm function meets the following
criteria:
• A) FEV1 > 2 L or FEV1/FVC of atleast 50%
• B) MVV > 50% of predicted value
• C) RV/ TLC < 50%
• If any of these criteria is not full filled – go for
more invasive & sophisticated, split lung
function tests.
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 CONTINUED……
• A predicted post op FEV1 Of atleast 800ml is
required to perform pneumonectomy
• If not- risk of significant resting CO2 retention &
dyspnoea is high.
• IF Sx inevitable – invasive tests : Pulmonary
artery occlusion test
• If after occlusion of pulm artery of segment to be
resected is not followed by pulm Htn ( mean
pulm art pr > 35 mmhg) AND hypoxemia(PaO2
<45 mmhg) – Assure that remaining lung can
accommodate entire C.O.
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THANKYOU

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