INTRODUCTION:

Pulmonary function testing is a valuable tool for evaluating the respiratory system, representing an important
adjunct to the patient history, various lung imaging studies, and invasive testing such as bronchoscopy and
open-lung biopsy. Insight into underlying pathophysiology can often be gained by comparing the measured
values for pulmonary function tests obtained on a patient at any particular point with normative values
derived from population studies. The percentage of predicted normal is used to grade the severity of the
abnormality. Practicing clinicians must become familiar with pulmonary function testing because it is often
used in clinical medicine for evaluating respiratory symptoms such as dyspnea and cough, for stratifying
preoperative risk, and for diagnosing common diseases such as asthma and chronic obstructive pulmonary
disease.

Pulmonary function tests (PFTs) is a generic term used to indicate a battery of studies or maneuvers that may
be performed using standardized equipment to measure lung function. PFTs can include simple screening
spirometry, formal lung volume measurement, diffusing capacity for carbon monoxide, and arterial blood
gases. These studies may collectively be referred to as a complete pulmonary function survey.

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
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).
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

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.

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.

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)

PATHOLOGICAL:
DISEASE OF RESPIRATORY MUSCLES

ABDOMINAL CONDITION : pain, dis.

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
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.
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.

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
Keep airway resistance low
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

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
2) Single breath count:
After deep breath, hold it and start counting till the next breath.
N- 30-40 COUNT

Indicates vital capacity

3) SCHNEIDERS 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

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.
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.
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

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.
8) Wright respirometer : measures tv, mv
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

9) 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.
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 N 2 test
 - Helium dilution method.
- Radio Xe scinitigram.
D) ventilation perfusion tests
A) ABG
B) single breath CO 2 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.
CANT 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
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 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.
Normal values vary and depend on:
Height
Age
 Gender
Ethnicity
MEASUREMENTS OF VOLUMES
TLC, RV, FRC MEASURED USING
Nitrogen washout method

Inert gas (helium) dilution method

Total body plethysmography

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 it 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

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.
BOYLES 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

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

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.
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

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

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) Pts 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.

DISEASE FEV1/FVC
STATES FVC FEV
1

1) OBSTRUCTIVE

NORMAL

2) STIFF NORMAL
LUNGS

3 ) RESP. NORMAL
MUSCLE
WEAKNESS

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 FEF 25-75%
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

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.

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

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 8 th 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
2) DYSPNEA DIFFENRENTIATION INDEX (DDI):
- To d/f dyspnea due to resp/ cardiac ds

DDI = PEFR x PaCO2

1000
- DDI- Lower in resp. pathology

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.
- Ficks law of diffusion : Vgas = A x D x (P1-P2)
T
 - D= diffusion coeff= solubility
MW

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

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. cant 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
Summary:

Lung function testing helps us to understand the physiologic working of the lungs and chest
mechanics.

Pulmonary function testing is the primary method used to diagnose, stage, and monitor various
pulmonary diseases.

Lung function testing requires operators to follow published guidelines for administering and
interpreting tests.
Physiologic Measures: Pulmonary Function Tests
Asthma Outcome
Paul L. Enright , Michael D. Lebowitz , and Donald W. Cockroft
+ Author Affiliations
DOI: 10.1164/ajrccm/149.2_Pt_2.S9 PubMed: 8298772

Abstract

When the effectiveness of asthma interventions are evaluated in the research setting, the physiologic
manifestation of asthmavariable airways obstructionis always objectively measured by some of the
following pulmonary function tests: (1) Baseline spirometry gives a highly accurate snapshot of asthma
severity and the degree of airways obstruction. The FEV1, derived from spirometry, is the most reproducible
pulmonary function parameter and is linearly related to the severity of airways obstruction. There are no
contraindications for the test, spirometers are widely available at reasonable cost, and methods and result
interpretation are comprehensively standardized. (2) The post-bronchodilator FEV1 measures the best lung
function that can be achieved by bronchodilator therapy on the day of the visit and therefore is a more stable
measure in asthmatics than comparing visit-to-visitbaseline FEV1. Although a positive acute response to
bronchodilator helps to confirm the diagnosis of asthma, the degree of bronchodilator reversibility from
visit-to-visit (change in reversibility) is not a useful index of asthma outcome. (3) Airway responsiveness
(bronchial challenge) measures the degree to which an individual withstands nonspecific stimuli that trigger
asthmatic attacks. The methacholine challenge test is safe and requires less than an hour, but it requires more
technical skill than baseline spirometry and is contraindicated in some situations. (4) Ambulatory monitoring,
using peak flow meters or hand-held spirometers, provides multiple measurements of the degree of
obstruction for days to weeks in the patient's natural setting. PEF meters are very inexpensive and almost all
asthmatics can use them, but PEF results are less reliable than the FEV1. The often asymptomatic obstruction
of an asthmatic has both short-term (within a day and day-to-day) and longer-term variations that are
triggered by naturally occurring stimuli. These changes are measured by PEF lability but not by spirometry
during clinic visits. (5) Other pulmonary function tests, such as absolute lung volumes and airways
resistance, may provide confirmatory data, but the instruments are large, expensive, and technically
demanding. The results of all the above pulmonary function tests are significantly correlated with each other
and with symptom scores and medication use in large groups of patients with widely varying degrees of
asthma severity. Since a gold standard with which to measure asthma severity does not currently exist, all
of these tests contribute an additional amount of unique information when measuring asthma outcome in a
clinical trial.
References

1. In: Clausen JL, Zarins LP (eds): Pulmonary Function Testing, Guidelines and
Controversies: Equipment, Methods, and Normal Values. New York: Academic Press,
1982.

2. Miller WF, Scacci R, Gast LR. Laboratory Evaluation of Pulmonary Function.

Philadelphia: JB Lippincott, 1987.

3. In: Albert RK, Spiro SG, Jett JR (eds): Comprehensive Respiratory Medicine. St
Louis: Mosby, 1999, p 43.

4. Miller MR, Hankinson J, Brusasco V, et al: American Thoracic Society/European

Respiratory Society Task Force: Standardization of spirometry. Eur Resp J. 2005, 26:
319-338.

5. Aaron SD, Dales RE, Cardinal P. How accurate is spirometry at predicting restrictive
pulmonary impairment? Chest. 1999, 115: 869-873.

6. American Thoracic Society. Lung function testing: Selection of reference values and
interpretative strategies. Am Rev Respir Dis. 1991, 144: 1202-1218.