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A Stepwise Approach to the Interpretation of Pulmonary Function Tests

JEREMY D. JOHNSON, MD, MPH, AND WESLEY M. THEURER, DO, MPH

info Am Fam Physician. 2014;89(5):359-366

local_library A more recent article on spirometry is available. (https://www.aafp.org/afp/2020/0315/p362.html)

assignment Author disclosure: No relevant financial affiliations.

Office-based pulmonary function testing, also known as spirometry, is a powerful tool for primary care physicians to diagnose and
manage respiratory problems. An obstructive defect is indicated by a low forced expiratory volume in one second/forced vital capacity
(FEV1/FVC) ratio, which is defined as less than 70% or below the fifth percentile based on data from the Third National Health and
Nutrition Examination Survey (NHANES III) in adults, and less than 85% in patients five to 18 years of age. If an obstructive defect is
present, the physician should determine if the disease is reversible based on the increase in FEV1 or FVC after bronchodilator treatment
(i.e., increase of more than 12% in patients five to 18 years of age, or more than 12% and more than 200 mL in adults). Asthma is typically
reversible, whereas chronic obstructive pulmonary disease is not. A restrictive pattern is indicated by an FVC below the fifth percentile
based on NHANES III data in adults, or less than 80% in patients five to 18 years of age. If a restrictive pattern is present, full pulmonary
function tests with diffusing capacity of the lung for carbon monoxide testing should be ordered to confirm restrictive lung disease and
form a differential diagnosis. If both the FEV1/FVC ratio and the FVC are low, the patient has a mixed defect. The severity of the
abnormality is determined by the FEV1 (percentage of predicted). If pulmonary function test results are normal, but the physician still
suspects exercise- or allergen-induced asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge,
exercise testing) should be considered.

Pulmonary function tests (PFTs) are useful for diagnosing the cause of unexplained respiratory symptoms and monitoring patients with
known respiratory disease. Many organizations, including the National Asthma Education and Prevention Program, Global Initiative for
Chronic Obstructive Lung Disease (GOLD), and American Thoracic Society (ATS), recommend using these tests.1–3 Office equipment
required to perform PFTs includes a computer, PFT software, pneumotach, printer, disposable mouthpiece, disposable nosepiece, and a 3-
L syringe for calibration. There is no difference between PFT measurements obtained in the office (spirometry) and those obtained in a
pulmonary function laboratory, as long as trained personnel calibrate, administer, and interpret the results.

PFTs take approximately 15 minutes for adults, 15 to 30 minutes for children, 45 minutes for pre- and postbronchodilator testing, and one
hour for full PFTs with diffusing capacity of the lung for carbon monoxide (DLCO) testing. Five years is usually the youngest age at which
children are able to cooperate with PFT procedures.1 Some PFT software will interpret the patient's results automatically, but these
machines should be used with caution because they may not follow current guidelines.

Physicians can use the following stepwise approach to not only interpret PFTs from their office or a pulmonary function laboratory, but
also determine when to order further testing and how to use PFT results to formulate a differential diagnosis. Figure 1 is an algorithm based
on this approach. Table 1 includes common terms related to PFTs.4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence References
Clinical recommendation rating

Physicians should use the Global Initiative for Chronic Obstructive Lung Disease criteria (FEV1/FVC ratio less C 6, 7

than 70%) to diagnose obstructive lung disease in patients 65 years and older who have respiratory symptoms
and are at risk of COPD (i.e., current or previous smoker).

Physicians should use the American Thoracic Society criteria (FEV1/FVC ratio less than the lower limit of C 8, 9

normal) to diagnose obstructive lung disease in patients younger than 65 years (regardless of smoking status)
and in nonsmokers 65 years and older.
 Evidence References
Clinical recommendation rating

If an obstructive defect is present, the physician should determine if it is reversible based on the increase in C 3

FEV1 or FVC after bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of age, or
more than 12% and more than 200 mL in adults).

If pulmonary function test results are normal but the physician still suspects exercise- or allergen-induced C 15, 16

asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing)
should be performed.

COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort
(https://www.aafp.org/afpsort).

BEST PRACTICES IN PULMONARY MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Source: For supporting citations, see https://www.aafp.org/afp/cw-table.pdf (https://www.aafp.org/afp/cw-table.pdf). To search Choosing Wisely
recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm
(https://www.aafp.org/afp/recommendations/search.htm).

FIGURE 1.

Interpreting Pulmonary Function Tests

Algorithm for interpreting pulmonary function test results. (ATS = American Thoracic Society; DLCO = diffusing capacity of the lung for carbon monoxide;
FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; GOLD = Global Initiative for Chronic Obstructive Lung Disease; LLN = lower limit
of normal.)
TABLE 1.

Glossary of Terms Related to Pulmonary Function Testing

Information from reference 4.

Getting Started

Before PFT results can be reliably interpreted, three factors must be confirmed: (1) the volume-time curve reaches a plateau, and expiration
lasts at least six seconds (Figure 2); (2) results of the two best efforts on the PFT are within 0.2 L of each other (Figure 3); and (3) the flow-
volume loops are free of artifacts and abnormalities.5 If the patient's efforts yield flattened flow-volume loops, submaximal effort is most
likely; however, central or upper airway obstruction should be considered.

FIGURE 2.

Evaluating Volume-Time Curves

Volume-time curve showing (A) normal plateau of the volume of air expired at one or two seconds (total expiration lasts at least six seconds), and (B) no
plateau; the volume continues to increase throughout expiration (this spirometry result should be interpreted with caution).

FIGURE 3.
Determining the Validity of Pulmonary Function Tests

The FEV1 and FVC measurements are within 0.2 L of each other during the two best efforts. Consistent, reproducible effort and flow loops confirm validity.
(FEF25%–75% = forced expiratory flow at 25% to 75% of FVC; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; PEF = peak
expiratory flow.)

Step 1: Determine If the FEV1/FVC Ratio Is Low

The first step when interpreting PFT results is to determine if the forced expiratory volume in one second/forced vital capacity (FEV1/FVC)
ratio is low, indicating an obstructive defect. Physicians have two options to determine if this ratio is low.

The first option is to follow the GOLD criteria, which use a cutoff of less than 70%.2 For patients five to 18 years of age, the National Asthma
Education and Prevention Program guideline says that a ratio of less than 85% is consistent with an obstructive defect as long as the patient
has symptoms consistent with obstructive lung disease.1

The second option is to follow the ATS criteria, which use the lower limit of normal (LLN) as the cutoff for adults.3 The LLN is a
measurement less than the fifth percentile of spirometry data obtained from the Third National Health and Nutrition Examination Survey
(NHANES III). Most modern PFT software can calculate the LLN. Alternatively, the calculator at http://hankconsulting.com/RefCal.html
(http://hankconsulting.com/RefCal.html) can be used for adults up to 75 years of age. Although the U.S. Food and Drug Administration has
not approved this calculator for clinical use, it appears to be accurate and valid.

GOLD VS. ATS CRITERIA

A large cohort study found that using the GOLD criteria (FEV1/FVC less than 70%) for diagnosis of chronic obstructive pulmonary disease
(COPD) in U.S. adults 65 years and older was more sensitive for COPD-related obstructive lung disease than using the ATS criteria
(FEV1/FVC less than the LLN).6 This finding was based on evidence that adults who met the GOLD criteria but not the ATS criteria (FEV1/FVC
less than 70% but greater than the LLN) had greater risk of COPD-related hospitalization (hazard ratio = 2.6; 95% confidence interval, 2.0 to
3.3) and mortality (hazard ratio = 1.3; 95% confidence interval, 1.1 to 1.5).7 Another cohort study looking at adults 65 years and older found
that, compared with the ATS criteria, the GOLD criteria had higher clinical agreement with an expert panel diagnosis for COPD and better
identified patients with clinically relevant events (e.g., COPD exacerbation, hospitalization, mortality).7 Until better criteria for the diagnosis
of COPD are found, physicians should use the GOLD criteria to diagnose obstructive lung disease in patients 65 years and older with
respiratory symptoms who are at risk of COPD (i.e., current or previous smoker).6,7

Other studies have found that using the GOLD criteria can miss up to 50% of young adults with obstructive lung disease and leads to
overdiagnosis in healthy non-smokers.8,9 Based on these studies, physicians should use the ATS criteria to diagnose obstructive lung
disease in patients younger than 65 years regardless of smoking status, and in nonsmokers who are 65 years and older.8,9

Step 2: Determine If the FVC Is Low

The physician must determine if the FVC is less than the LLN for adults or less than 80% of predicted for those five to 18 years of age,
indicating a restrictive pattern.3,10,11 The LLN can be determined using the calculator at http://hankconsulting.com/RefCal.html
(http://hankconsulting.com/RefCal.html). A restrictive pattern can indicate restrictive lung disease, a mixed pattern (if a patient has an
obstructive defect and a restrictive pattern), or pure obstructive lung disease with air trapping. Table 2 summarizes the first two steps of PFT
interpretation.1–3,10,11

TABLE 2.

Pulmonary Function Test Interpretation

FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; LLN = lower limit of normal (defined as below the fifth percentile of spirometry
data obtained from the Third National Health and Nutrition Examination Survey).

*—The 70% criteria should be used only for patients 65 years and older who have respiratory symptoms and are at risk of chronic obstructive pulmonary
disease (i.e., current or previous smoker).

Information from references 1 through 3, 10, and 11.

Step 3: Confirm the Restrictive Pattern

If the patient's initial PFT results indicate a restrictive pattern or a mixed pattern that is not corrected with bronchodilators, the patient
should be referred for full PFTs with DLCO testing. DLCO is a quantitative measurement of gas transfer in the lungs. Diseases that decrease
blood flow to the lungs or damage alveoli will cause less efficient gas exchange, resulting in a lower DLCO measurement.

During the DLCO test, patients inhale a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%), and nitrogen (68.7%)12 then hold
their breath for 10 seconds before exhaling. The amounts of exhaled helium and carbon monoxide are used to calculate the DLCO. Carbon
monoxide is used to estimate gas transfer instead of oxygen due to its much higher affinity for hemoglobin. A baseline hemoglobin level
should be obtained before DLCO testing because results are adjusted for the hemoglobin level.

Full PFTs provide the patient's total lung capacity. The restrictive pattern is confirmed as a true restrictive defect if the total lung capacity is
less than 80% of predicted in patients five to 18 years of age, or less than the LLN in adults. If full PFTs cannot be obtained, the FVC can be
used to infer a restrictive defect; however, FVC has a poor positive predictive value.13,14

Step 4: Grade the Severity of the Abnormality

If an obstructive defect, a restrictive pattern, or a mixed pattern is present, as defined by steps 1 and 2, the physician should grade the
severity of the abnormality based on the FEV1 percentage of predicted. The ATS system for grading the severity of a PFT abnormality is
summarized in Table 3.3

TABLE 3.

American Thoracic Society Grades for Severity of a Pulmonary Function Test Abnormality

FEV1 = forced expiratory volume in one second.

Adapted with permission from Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26(5):957.

Step 5: Determine Reversibility of the Obstructive Defect

If the patient has an obstructive defect, the physician should determine if it is reversible based on the increase in FEV1 or FVC after
bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of age, or more than 12% and more than 200 mL in
adults).3 Figure 4 shows a fully reversible obstructive defect. Obstructive defects in persons with asthma are usually fully reversible,
whereas defects in persons with COPD typically are not.

FIGURE 4.
Obstructive Defect with Reversibility

The obstructive defect is reversible because at least one of the two measurements (FVC or FEV1) increased by at least 0.2 L and by at least 12%. (FEF25%–75% =
forced expiratory flow at 25% to 75% of FVC; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; LLN = lower limit of normal.)
If PFTs show a mixed pattern and the FVC corrects to 80% or more of predicted in patients five to 18 years of age or to the LLN or more in
adults after bronchodilator use, it is likely that the patient has pure obstructive lung disease with air trapping.

Step 6: Bronchoprovocation

If PFT results are normal but the physician still suspects exercise- or allergen-induced asthma, the next step is bronchoprovocation, such
as a methacholine challenge, a mannitol inhalation challenge, exercise testing, or sometimes eucapnic voluntary hyperpnea testing.15,16
When the FEV1 is 70% or more of predicted on standard spirometry, bronchoprovocation should be used to make the diagnosis. If the FEV1
is less than 70% of predicted, a therapeutic trial of a bronchodilator may be considered.17

METHACHOLINE CHALLENGE

The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results.15,17 A
positive methacholine challenge result is defined as a greater than 20% reduction in FEV1 at or before administration of 4 mg per mL of
inhaled methacholine.15 The result is considered borderline if the FEV1 drops by 20% at a dose between 4 and 16 mg per mL.15

MANNITOL INHALATION CHALLENGE

The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the
methacholine challenge, but has a higher specificity for the diagnosis of asthma.16,17 A positive mannitol inhalation challenge result is
defined as a greater than 15% decrease from baseline in FEV1 at a cumulative dose of 635 mg or less of inhaled mannitol, or a 10% decrease
between any two consecutive doses.16,17

EXERCISE TESTING

A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only
modest sensitivity and specificity for the diagnosis of asthma.17 In this test, baseline spirometry is measured, followed by exercise on a
treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight
minutes.17 Inhaled medical-grade dry air or an air-conditioned room, with air temperature between 60°F and 77°F (20°C and 25°C) and
humidity level less than 50%, is recommended. The patient must wear a nose clip.

Postchallenge FEV1 testing takes place at 1- to 3-, 5-, 10-, 15-, 20-, and 30- to 45-minute time points. The test is considered positive if a
10% or greater decline from baseline in FVC or FEV1 occurs over any two consecutive time points in the 30 minutes following the cessation
of exercise.15,18

EUCAPNIC VOLUNTARY HYPERPNEA TESTING

Eucapnic voluntary hyperpnea testing is available only at specialized centers and is used by the International Olympic Committee Medical
Commission's Independent Panel on Asthma to identify exercise-induced bronchoconstriction in elite athletes desiring to use
bronchodilators before competition.19

Step 7: Establish the Differential Diagnosis

Once PFT results have been interpreted, the broad differential diagnosis should be considered. Table 4 lists common causes of lung
disorders.20–35 Table 5 is the differential diagnosis based on DLCO results.3,12,14,36–44

TABLE 4.

Common Causes of Obstructive and Restrictive Lung Disease

Information from references 20 through 35.

TABLE 5.
Differential Diagnosis Based on DLCO Results

Interpretation: High = greater than 120% of predicted; Normal = LLN to 120% of predicted; Low (mild decrease) = greater than 60% of predicted and less than
LLN; Low (moderate decrease) = 40% to 60% of predicted; Low (severe decrease) = less than 40% of predicted. If the laboratory does not report LLN,
observational studies indicate that the LLN for men is approximately 80%, and the LLN for women is approximately 76%.36

DLCO = diffusing capacity of the lung for carbon monoxide; LLN = lower limit of normal.

Information from references 3, 12, 14, and 36 through 44.

Step 8: Compare Current and Prior PFT Results

If a patient's prior PFT results are available, they should be compared with the current results to determine the course of the disease or
effects of treatment.

Data Sources: We conducted literature searches using Ovid, PubMed, the Cochrane database, and Essential Evidence Plus, focusing on the
keywords spirometry and pulmonary function test(s), with an emphasis on the diagnosis and/or interpretation of results. The section on
DLCO was reviewed in UpToDate in October 2011 to identify additional primary literature regarding this test. Search dates: September to
October 2011, May 2012, and August 2013.

Author Information
JEREMY D. JOHNSON, MD, MPH, is program director at the Tripler Army Medical Center Family Medicine Residency in Honolulu, Hawaii.

WESLEY M. THEURER, DO, MPH, is a faculty development fellow at Madigan Army Medical Center, Fort Lewis, Wash. At the time this article
was written, he was associate program director at the Tripler Army Medical Center Family Medicine Residency.

The views expressed in this abstract/manuscript are those of the authors and do not reflect the official policy or position of the Department
of the Army, Department of Defense, or the U.S. government.

The authors thank Diane Kunichika for her assistance with the literature search, and LTC Minhluan Doan for his assistance with researching
pulmonary function testing in children.

Address correspondence to Jeremy D. Johnson, MD, MPH, Tripler Army Medical Center, 1 Jarrett White Rd., Honolulu, HI 96859 (e-mail:
[email protected] (mailto:[email protected])). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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