Pulmonary-Function-Tests and it's importance ppt

PULMONARY FUNCTION
TESTS
Dr. Pooja Chopra
poojadeep_dreamsin@yahoo.co.in
www.anaesthesia.co.in

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.

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).

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

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

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)

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.

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.

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

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)

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

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.

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.

DIFFERENT POSTURES AFFECTING VC
• POSITION
 TRENDELENBERG
 LITHOTOMY
 PRONE
 RT. LATERAL
 LT. LATERAL
• DECREASE IN VC
 14.5%
 18%
 10%
 12%
 10%

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.

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.

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
 Decreses under anaesthesia
• with spontaneous Respiration – decreases by
20%
• With paralysis – decreases by 16%

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.

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

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.

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.

 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
GOALS, CONTINUED……..

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

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)

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

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

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

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.

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. www.anaesthesia.co.in

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

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.

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.
• Accurate measurement in the range of 3.7-20l/min.(±10%)
• USES: 1)BED SIDE PFT
• 2) ICU – WEANIG PTS. FROM Ventilation.

DEBONO’S WHISTLE

BED SIDE PFT
9) MICROSPIROMETERS – MEASURE VC.
10) BED SIDE PULSE OXIMETRY
11) ABG.

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.

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

3) CARDIOPULMONARY INTERACTION:
A) Qualitative tests:
- History , examination
- Abg
- Stair climbing test
B) Quantitative tests
- 6 min. Walk test (gold standard)

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.

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

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.

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.

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

Normal Flow-Volume Curve and
Spirogram

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

Acceptable and Unacceptable
Spirograms (from ATS, 1994)

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

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

Normal vs. Obstructive vs. Restrictive
(Hyatt,
2003)

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

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

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

What about lung volumes and obstructive
and restrictive disease?
(From Ruppel,
2003)

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

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

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

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

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)

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

MEASUREMENT OF DYNAMIC LUNG
VOLUMES
• TIMED EXPIRED SPIROGRAMS
FEF25–75% = forced
expiratory flow during
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).

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.

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

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

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.

CONTINUED……
DISEASE STATES FVC FEV1 FEV1/FVC
1) OBSTRUCTIVE NORMAL ↓ ↓
2) STIFF LUNGS ↓ ↓ NORMAL
3 ) RESP. MUSCLE
WEAKNESS
↓ ↓ NORMAL

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.
- .

- 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

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

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

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

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.

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

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

Continued……
DISEASE MSL. STRENGTH Raw PL
N-M WEAKNESS ↓ N N
EMPHYSEMA N N ↓
ASTHMA/BRONCHI
TIS
N ↑ N
PERIPHERAL
AIRWAY DIS.
N N N

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

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.

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

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.

Flow-Volume Loops
(Rudolph and
Rudolph, 2003)

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

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

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

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

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

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

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

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

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

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.

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.

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.

THANKYOU

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