Chapter PULMONARY FUNCTION TESTS

15

Spirometry and flow volume loops

Spirometry measures volume against time:
 FEV1: forced expiratory volume in 1 sec.
 FVC: forced vital capacity.

 Ratio of FEV1:FVC (normal ratio >70%).

Flow volume loops display flow (L/sec) against volume (L):

 Flow is greatest when the lung volume is greatest, hence the rapid rise to peak expiratory

flow rate (PEFR).

 As volume falls, elastic recoil forces are reduced and airways narrow; flow reduces until the

residual volume (RV) is reached.

 FEF25–75%: forced expiratory flow averaged for the middle half of the FVC manoeuvre; a

more sensitive but less reproducible measure of medium/small airway narrowing than
FEV1.

Flow/volume loop
Flow (L/sec) Normal flow volume loop
Obstructive loop
Restrictive loop

Expiratory arm

Volume (L)
TLC
RV

Inspiratory arm

Obstructive spirometry

Obstructive lung disease: asthma, COPD, A1AT deficiency, bronchiectasis, CF.

FEV1:FVC ratio <70% with FEV1 <80% predicted:
 FEV1 falls disproportionately greater than FVC.
92 PULMONARY FUNCTION TESTS

Flow volume loop: concave flattening of expiratory arm (‘scalloping’):

 Flow diminishes during expiration due to airway collapse, reducing lung volumes and
increasing resistance.
 Prolonged time to full expiration but normal inspiratory curve.

Restrictive spirometry

Restrictive lung disease: interstitial lung disease, pleural disease, neuromuscular disease,
diaphragm dysfunction, kyphoscoliosis, obesity, pregnancy.

FEV1:FVC ratio >80%:
 Reduction of FEV1 and FVC.

Flow volume loop: small but with relatively normal inspiratory/expiratory curves.

Mixed obstructive/restrictive spirometry

FEV1:FVC ratio <70% and reduction in FVC.

The result of concurrent lung pathology or airway closure with gas trapping; differentiate
according to TLC.

Upper airways obstruction

Fixed upper airways obstruction

Upper airway pathology that does not vary with inspiration or expiration:
 Maximal flow rates limited.

Flow volume loop: characteristic flattening in both inspiration and expiration.

Causes: tracheal/bronchial stenosis, goitre, upper airway tumours.

Fixed upper airways obstruction on flow

Flow (L/sec)
volume loop

Normal flow volume loop

Fixed airways obstruction—

both inspiratory and expiratory
loops flattened

Volume (L)

Variable upper airways obstruction

Different patterns depend on the level of the narrowing.

Variable intrathoracic obstruction:
 Inspiration:

 Decreased intrathoracic pressure splints open the airway lumen at the site of intrathoracic

obstruction, maintaining flow.

 PULMONARY FUNCTION TESTS 93

 Normal inspiratory flow curve.

 Expiration:
 Increased intrathoracic pressure narrows the airway lumen at the site of intrathoracic

obstruction, limiting flow.

 Flattened expiratory flow curve.

 Causes: tracheomalacia, polychondritis, low tracheal/bronchial tumours.

Variable intra thoracic upper airways

Flow (L/sec) obstruction on flow volume loop

Normal flow volume loop

Variable intrathoracic
obstruction—normal inspiratory
loop, but flattened expiratory
loop

Volume (L)

Variable extrathoracic obstruction:

 Inspiration:
 Acceleration of air into the lungs reduces intraluminal pressures causing collapse at the site

of extrathoracic obstruction.
 Flattened inspiratory flow curve.

Variable extra thoracic upper airways

Flow (L/sec) obstruction on flow volume loop

Normal flow volume loop

Variable extrathoracic
obstruction—normal
expiratory loop but flattened
inspiratory loop

Volume (L)
94 PULMONARY FUNCTION TESTS

 Expiration:
 Expiration forces air via a narrowed (± expandable) extrathoracic airway.

 Normal expiratory flow curve.

 Causes: vocal cord paralysis (unilateral/bilateral), airway burns, laryngeal oedema, glottic
strictures.

Lung volume measurements

Volumes: tidal volume (TV), inspiratory reserve volume (IRV), expiratory reserve volume (ERV),
residual volume (RV).

Capacities (comprise ≥2 of the basic lung volumes): total lung capacity (TLC = RV + IRV + ERV
+ TV), vital capacity (VC = TLC − RV), functional residual capacity (FRC = RV + ERV).

Helium dilution

Used to measure FRC.

Patient inhales gas mixture with helium and holds breath for 10 secs.

Helium distributes throughout airways excluding trapped lung gas.

Measures only communicating airspaces, not bullae or cavities.

Distal airway obstruction may therefore result in underestimation of FRC.

Whole-body plethysmography (WBP)

Patient sits in airtight chamber and makes inspiratory and expiratory effort against a closed valve.

Measures non-communicating volume as well as communicating volume.

Difference between WBP and helium dilution indicates volume of bullous disease.

Lung volumes in obstructive lung disease

Key feature is an increase in RV.

Air trapping: low VC, normal TLC, high RV and RV:TLC.

Hyperinflation: normal VC, high TLC, high RV and RV:TLC.

Lung volumes in restrictive lung disease

Key feature is a decrease in TLC.

Parenchymal lung disease: reductions in all lung volumes; RV:TLC may remain normal.

Raised BMI: reductions in all lung volumes, especially FRC and ERV; normal RV:TLC.

Neuromuscular weakness: low VC, low TLC, high RV and RV:TLC in severe expiratory muscle
weakness (may cause confusion with obstructive disorders).

Gas transfer measurements

TLCO: carbon monoxide transfer factor (mmol/min/kPa).

KCO: transfer factor corrected for alveolar volume (TLCO/VA).

VA: alveolar volume.

Carbon monoxide (CO) transfer method

Patient inhales gas mixture (CO, helium, oxygen, and nitrogen), holds breath for 10 secs and
exhales into a sample bag.

Helium dilution is used to estimate alveolar/total lung volumes.
 PULMONARY FUNCTION TESTS 95

CO uptake is measured as a concentration fall in CO and is used to calculate diffusing capacity

(TLCO); uptake is limited by both perfusion and diffusion.

Increased TLCO

Pulmonary haemorrhage, left-to-right shunt, ± acute asthma.

Reduced TLCO

Anaemia reduces TLCO therefore correct for haematocrit.

Emphysema, interstitial lung disease, and pulmonary vascular disease:
 Low TLCO, low KCO.

Non-pulmonary processes that reduce TLC (e.g. chest wall deformity, neuromuscular weakness,
obesity, diffuse pleural thickening, lung resection, small lungs):
 Low TLCO, normal KCO.

Airway hyper-responsiveness
Reversibility

Positive if increase in FEV1 or FVC > 12% or 200 ml to inhaled bronchodilator.

Bronchial provocation tests

For patients with suspected airway hyper-responsiveness but normal spirometry.

Direct: agents such as histamine and methacholine act directly on smooth muscle to cause
contraction and airway narrowing:
 Methacholine challenge testing:

 Methacholine inhaled at increasing concentrations with repeated spirometry.

 Positive result with fall in FEV1 >20% (PC20: provocative concentration in mg/mL).

 Lower PC20 indicates lower concentration of methacholine needed to induce bronchos-

pasm so more sensitive airway.

Indirect: hyperosmolar stimuli or hyperpnoea trigger inflammatory mediator release to indirectly
cause smooth muscle contraction.

Exercise testing
Incremental shuttle walk test (ISWT)

Patient walks 10-m course with increasing speed to keep up with a tape of preset ‘bleeps’ at
decreasing time intervals; no encouragement.

Minimum clinically significant improvement (MCSI) post intervention is 47.5 m.

Better correlation with peak oxygen uptake than 6MWT but less well validated; also more
cardiovascular risk.

6-minute walk test (6MWT)

Patient walks quickly on a flat surface for 6 mins around a 30-m course.

Allowed to stop and rest during the test; standard phrases of encouragement used.

Normal estimates: 580 m (men), 500 m (women), significant improvement ≥ 54 m.

Correlates well with functional scores of disability.
96 PULMONARY FUNCTION TESTS

Cardiopulmonary exercise testing (CPX)

Used to distinguish between respiratory and cardiac causes of breathlessness.

Multiple parameters of lung function and cardiac function measured at rest.

Repeated at incremental levels of exercise:
 Cardiac function: ECG, BP, peak HR, and peak oxygen consumption.

 Ventilatory function: tidal volume, expiratory capacity, spirometry.

 Gas exchange efficiency: PaO2, alveolar–arterial (A–a) gradient, oxygen saturations.

Respiratory muscle assessment

Diaphragm assessment

Measure sitting or standing VC then repeat with patient lying supine:
 Fall in VC <10%: probably normal.
 Fall in VC 10–20%: suggests diaphragmatic weakness.

 Fall in VC >20%: significant weakness or paralysis.

Obesity causes resistance to diaphragm movement and may result in fall in supine VC without
focal pathology.

Inspiratory muscle assessment

Sniff test: measure negative pressure generated at the nose when sniffing:
 Indication of inspiratory muscle strength.

Transdiaphragmatic pressure measurement:
 Balloons placed in oesophagus above and below diaphragm.

 Measurement of diaphragmatic function.

Phrenic nerve stimulation: using high-intensity magnets or electrical stimulation:

 Passive assessment of diaphragmatic function.