Overview of pulmonary function testing in adults

Author
Paul L Enright, MD Section Editor
James K Stoller, MS, MD Deputy Editor
Helen Hollingsworth, MD

Last literature review version 19.1: January 2011 | This topic last updated: August 17,
2010 (More)

INTRODUCTION — Evaluation of pulmonary function is important in many clinical

situations, both when the patient has a history or symptoms suggestive of lung disease,
and when risk factors for lung disease are present, such as cigarette smoking [1]. An
overview of pulmonary function testing will be presented here, summarizing the types
of pulmonary function tests and their indications. Specific aspects of pulmonary
function testing are discussed elsewhere. (See "Office spirometry" and "Reference
values for pulmonary function testing" and "Diffusing capacity for carbon monoxide".)

PULMONARY FUNCTION TESTS — The major types of pulmonary function tests

include spirometry, measurement of lung volumes, and quantitation of diffusing
capacity. Measurements of maximal respiratory pressures and flow-volume loops,
which record forced inspiratory and expiratory flow rates, are also useful in specific
clinical circumstances (table 1).

Spirometry — Spirometry, which includes measurement of forced expiratory volume in

one second (FEV1) and forced vital capacity (FVC), is the most readily available and
most useful pulmonary function test. It takes 10 to 15 minutes, uses a $2000 instrument,
and carries no risk. (See "Office spirometry" and "Flow-volume loops".)

The slow vital capacity (SVC) can also be measured with spirometers which collect data
for at least 30 seconds. The SVC may be a useful measurement when the forced vital
capacity (FVC) is reduced and airways obstruction is present. Slow exhalation results in
a lesser degree of airway narrowing, and frequently the patient can exhale a larger, even
normal, volume. In contrast, the vital capacity with restrictive disease is reduced during
both slow and fast maneuvers. Thus, if the slow or forced vital capacity is within the
normal range, a significant restrictive disorder is virtually excluded, and it is generally
unnecessary to measure static lung volumes (residual volume and total lung capacity)
[2].

Flow-volume loop — Flow-volume loops, which include forced inspiratory and

expiratory maneuvers, should be performed whenever stridor is heard over the neck
during forced breathing or for evaluation of unexplained dyspnea. Airway obstruction
located in the pharynx, larynx, or trachea (upper airways) is usually impossible to detect
from standard FVC maneuvers. Reproducible forced inspiratory vital capacity (FIVC)
maneuvers detect variable upper airway obstruction, as can be seen with vocal cord
paralysis or dysfunction, which causes a characteristic limitation of flow (plateau)
during forced inhalation but little if any obstruction during exhalation (figure 1). (See
"Flow-volume loops".)

Less commonly, a fixed upper airway obstruction (UAO) (eg, tracheal stenosis) causes
flow limitation during both forced inhalation and forced exhalation maneuvers (figure
1). However, the flow-volume loop is not sensitive for detecting a fixed UAO, since the
tracheal lumen is often reduced to less than 1 cm before a plateau is recognized. Poor
effort mimics the flow-volume loop shapes of upper airway obstruction, but can be
excluded when three or more maneuvers are seen to be reproducible.

Post-bronchodilator — Administration of albuterol by metered-dose inhaler (MDI) is

indicated during an initial workup if baseline spirometry demonstrates airway
obstruction or if one suspects asthma. Spirometry should be repeated ten minutes after
administration of a bronchodilator; proper MDI technique is important to prevent false
negative results. (See "The use of inhaler devices in adults".)

In a patient with airway obstruction, an increase in the FEV1 of more than 12 percent
and greater than 0.2 L suggests acute bronchodilator responsiveness [3]. However, the
lack of an acute bronchodilator response should not preclude a six to eight week
therapeutic trial of bronchodilators and/or inhaled glucocorticoids, with reassessment of
clinical status and change in FEV1 at the end of that time.

Lung volumes — Measurement of the total lung capacity (TLC) may be helpful when
the vital capacity is decreased. For example, in the setting of chronic obstructive
pulmonary disease (COPD) with a low vital capacity, measurement of the TLC can help
determine if there is a superimposed restrictive disorder.

There are four methods of measuring TLC:

Helium dilutionNitrogen washoutBody plethysmographyChest radiograph

measurements

The first two methods are used extensively in hospital pulmonary function laboratories,
but they may underestimate the TLC in patients with moderate to severe COPD. The
gold standard for measurement of TLC, particularly in the setting of significant airflow
obstruction, is body plethysmography.

Measurements of TLC using the chest radiograph correlate within 15 percent of those
obtained by body plethysmography [4]. These measurements can be made in the office
in about five minutes from a standard PA and lateral chest radiograph, using a $300
planimeter. Since the TLC is equivalent to the amount of air seen in the lungs on a chest
radiograph taken at maximal inspiration, it is important that the subject inhales
maximally as the image is created.

Maximal respiratory pressures — Measurement of maximal inspiratory and expiratory

pressures is indicated whenever there is an unexplained decrease in vital capacity or
respiratory muscle weakness is suspected clinically. Maximal inspiratory pressure
(MIP) is the maximal pressure that can be produced by the patient trying to inhale
through a blocked mouthpiece. Maximal expiratory pressure (MEP) is the maximal
pressure measured during forced expiration (with cheeks bulging) through a blocked
mouthpiece after a full inhalation. Repeated measurements of MIP and MEP are useful
in following the course of patients with neuromuscular disorders. The slow vital
capacity may also be followed, but it is less specific and usually less sensitive.

Maximal inspiratory and expiratory pressures are easily measured using a simple
mechanical pressure gauge connected to a mouthpiece. MIP measures the ability of the
diaphragm and the other respiratory muscles to generate inspiratory force, reflected by a
negative airway pressure. The average MIP and MEP for adult men are -100 cmH2O
and +170 cmH2O, respectively, while the corresponding values for adult women are
about -70 cmH2O and +110 cmH2O, respectively [5,6]. The lower limit of the normal
range is about two-thirds of these values [3].

Diffusing capacity — Measurement of the single-breath diffusing capacity for carbon

monoxide (DLCO) is quick, safe, and useful in the evaluation of both restrictive and
obstructive disease. It requires use of a piece of equipment that costs $20,000. In the
setting of restrictive disease, the diffusing capacity helps distinguish between intrinsic
lung disease, in which DLCO is usually reduced, from other causes of restriction, in
which DLCO is usually normal. In the setting of obstructive disease, the DLCO helps
distinguish between emphysema and other causes of chronic airway obstruction. (See
"Diffusing capacity for carbon monoxide".)

Oxygen desaturation during exercise — The six-minute walk test (6MWT) is a good
index of physical function and therapeutic response in patients with chronic lung
disease, such as COPD or idiopathic pulmonary fibrosis [7-9]. A fall in SpO2 of more
than 4 percent (ending below 93 percent) suggests significant desaturation, and
confirmation with arterial blood gas (ABG) measurements may be indicated. (See
"Pulse oximetry".)

During a 6MWT, healthy subjects can typically walk 400 to 700 m [7]. An
improvement of more than 70 m in distance walked appears to be clinically important
and noticeable to patients. Estimates of the minimum decrease in distance walked that is
important to patients range from 28 m to 54 m [8,10].

Oxygen saturation during the 6MWT can also be used to titrate the amount of oxygen
needed to maintain adequate saturation during walking. (See "Long-term supplemental
oxygen therapy".)

Arterial blood gases — Arterial blood gases (ABGs) may be a helpful adjunct to
pulmonary function testing in selected patients. The primary role of measuring ABGs in
stable outpatients is to confirm hypoventilation when it is suspected on the basis of
clinical history (eg, respiratory muscle weakness, advanced COPD), an elevated serum
bicarbonate level, and/or chronic hypoxemia. ABGs also provide a more detailed
assessment of the severity of hypoxemia in patients who have low normal
oxyhemoglobin saturation.

INDICATIONS — Pulmonary function testing is useful for evaluation of a variety of

forms of lung disease or for assessing the presence of disease in a patient with known
risk factors, such as smoking. Other indications for pulmonary function tests include:
Evaluation of symptoms such as chronic persistent cough, wheezing, dyspnea, and
exertional cough or chest pain.Objective assessment of bronchodilator
therapy.Evaluation of effects of exposure to dusts or chemicals at work.Risk evaluation
of patients prior to thoracic or upper abdominal surgery.Objective assessment of
impairment or disability.

Chronic dyspnea — Many lung diseases begin slowly and insidiously and finally
manifest themselves with the nonspecific symptom of dyspnea on exertion. Pulmonary
function tests are an essential part of the workup of such patients. In the outpatient
setting, in which several days to weeks are available to make the diagnosis, a cost
efficient method of ordering pulmonary function tests is to start with spirometry and
then order further tests in a stepwise fashion to refine the diagnosis (figure 2). (See
"Approach to the patient with dyspnea".)

When a patient is hospitalized and a diagnosis is needed within a day or two, a battery
of pulmonary function tests may be ordered, often including spirometry before and after
(pre- and post-) bronchodilator therapy, static lung volumes, and diffusing capacity. If
the cause of dyspnea on exertion remains uncertain after these tests have been
performed, cardiopulmonary exercise testing should be considered.

Asthma — Spirometry before and after a bronchodilator is indicated during the initial
workup of patients suspected of having asthma (figure 3A-B). Spirometry is also
indicated during most follow-up office visits to provide an objective measure of the
therapeutic response [11]. (See "Diagnosis of asthma in adolescents and adults" and
"Use of pulmonary function testing in the diagnosis of asthma".)

Cough or chest tightness with exercise or exposure to cold air, dusts, or fumes suggests
bronchial hyperresponsiveness (BHR). However, BHR may not be detected by pre- and
post-bronchodilator spirometry if the patient is asymptomatic at the time of evaluation.
Commonly, the patient is asked to return for retesting when symptoms occur; however,
this delays the diagnosis and may be impractical. Inhalation challenge testing will
usually confirm or exclude the diagnosis of asthma in less than an hour. (See
"Bronchoprovocation testing".)

An alternative to inhalation challenge testing for the detection of airway hyperreactivity

is measurement of airway lability for two weeks in the patient's own environment, using
ambulatory monitoring of peak flow or FEV1. Children with asthma (not controlled by
medication) typically demonstrate peak flow lability (amplitude/mean) in excess of 30
percent, while adults with active asthma have PEF lability greater than 20 percent. (See
"Peak expiratory flow rate monitoring in asthma".)

A forced inspiratory maneuver performed as part of a flow-volume loop may be useful

in detecting "vocal cord dysfunction" in atypical patients with a diagnosis of asthma
who do not respond appropriately to therapy. (See "Diagnosis of wheezing illnesses
other than asthma in adults" and "Paradoxical vocal cord motion".)

Chronic obstructive pulmonary disease — Spirometry is the best method to detect or

confirm airways obstruction in smokers with dyspnea (figure 3A-B) [12]. In these cases,
the FEV1/FVC ratio and the FEV1 are decreased. Measurement of lung volumes is
rarely useful in patients with obstructive spirometric parameters because it does not
allow reliable differentiation of asthma and chronic obstructive pulmonary disease, and
a concomitant restrictive ventilatory defect is detected in <10 percent of patients with a
reduced FVC [13]. (See "Chronic obstructive pulmonary disease: Definition, clinical
manifestations, diagnosis, and staging".)

Once the diagnosis of COPD is established, the course and response to therapy are best
followed by observing changes in the FEV1, as was done in the multicenter Lung
Health Study [14]. Continued smoking in a patient with airways obstruction often
results in an abnormally rapid decline in FEV1 (90 to 150 mL/yr). On the other hand,
smoking cessation often results in an increase in FEV1 during the first year, followed by
a nearly normal rate of FEV1 decline (30 mL/yr). Both a low FEV1 and chronic mucus
hypersecretion are predictors of hospitalization due to COPD [15].

Once the airways obstruction due to COPD has become very severe, with an FEV1 of
0.7 L or less, changes from visit to visit are usually within the error of the measurement
(0.2 liters). In this circumstance, measurements of oxygen saturation during exercise
and distance walked during six minutes may be more clinically meaningful for
evaluating disease progression or therapeutic response than are changes in spirometry
values [9,16].

Measurement of the diffusing capacity for carbon monoxide helps to distinguish

between emphysema and other causes of chronic airway obstruction. As an example,
emphysema lowers the DLCO, obstructive chronic bronchitis does not affect the DLCO,
and asthma frequently increases the DLCO. (See "Diffusing capacity for carbon
monoxide".) Changes in the DLCO in patients with established, smoking-related COPD
are probably not clinically useful during follow-up visits, unless dyspnea suddenly
worsens without an obvious cause.

Restrictive lung disease — The many disorders which cause reduction of lung volumes
(restriction) may be divided into three groups (figure 3A-B):

Intrinsic lung diseases, which cause inflammation or scarring of the lung tissue
(interstitial lung disease) or fill the airspaces with exudate or debris (acute
pneumonitis).Extrinsic disorders, such as disorders of the chest wall or the pleura,
which mechanically compress the lungs or limit their expansion.Neuromuscular
disorders, which decrease the ability of the respiratory muscles to inflate and deflate the
lungs.

The history, physical examination, and chest radiograph are often helpful in
distinguishing among these disorders. Spirometry is useful in detecting restriction
(reduction) of lung volumes, but it rarely helps in establishing the cause. The DLCO is
useful for differentiating intrinsic lung diseases, in which DLCO is generally reduced,
from other causes of lung volume restriction, including neuromuscular disease or
musculoskeletal deformity, in which DLCO is generally normal. (See "Diffusing
capacity for carbon monoxide".)

Changes in the DLCO are also useful for following the course of or response to therapy
in patients with interstitial lung disease. Pulse oximetry during a 6MWT is also useful in
this setting, since oxygen saturation often falls during mild exercise in patients with
interstitial lung disease and responds to successful therapeutic interventions [17]. (See
"Approach to the adult with interstitial lung disease: Diagnostic testing".)

Preoperative testing — Spirometry is useful for determining the risk of postoperative

pulmonary complications in certain high-risk situations, including patients known to
have COPD or asthma, current smokers, and those scheduled for thoracic or upper
abdominal surgery [18]. The degree of airways obstruction (or an elevated PCO2 for
patients with COPD) predicts the risk of postoperative pulmonary complications, such
as atelectasis, pneumonia, and the need for prolonged mechanical ventilation. If
spirometry demonstrates moderate to severe obstruction and the surgery can be delayed,
a prophylactic program of pulmonary hygiene, including smoking cessation, inhaled
bronchodilators or steroids, and antibiotics for bronchitis, will reduce the risk. However,
the results of spirometry should not be used to deny surgery. Combining the results of
spirometry with radioisotope or CT lung scans is also useful for predicting the
remaining lung function following a lobectomy or pneumonectomy.

A number of studies indicate that the maximum oxygen uptake (as a percent of
predicted), determined by cardiopulmonary exercise testing, is better than spirometry
for predicting postsurgical complications [19], but the cost:benefit ratio is unknown.
(See "Preoperative evaluation for lung resection".)

Impairment or disability — Most schemes for evaluation of respiratory impairment use

pulmonary function tests, but the results in studies performed at rest are only a rough
indication of an individual's ability to perform a given job. It is ideal to measure
maximal oxygen consumption (VO2max), but this test is often not available to the
primary care physicians who perform "disability" testing, or the expense is not
reimbursed [20,21].

The American Medical Association provides guidelines for the classification of

respiratory impairment based upon the results of spirometry or maximal oxygen
consumption [22]. Of course, the results must be of good quality. Severe impairment
(AMA class 4 with estimated 50 to 100 percent impairment) is defined as any one of the
following:

Dyspnea after walking less than 100 meters on level ground.FVC less than 50 percent
predicted.FEV1 less than 40 percent predicted.DLCO less than 40 percent
predicted.VO2max less than 15 mL/kg per min

The Social Security Administration defines total respiratory disability using either
height-corrected FEV1 (1.1 to 1.4 L) or a DLCO less than 30 percent predicted [23]. In
one study, approximately 33 percent of patients who met the above criteria were dead
after four years, compared with 7 percent of those who applied for disability but did not
meet these criteria. (See "Evaluation of pulmonary disability".)

SUMMARY AND RECOMMENDATIONS

Pulmonary function testing is indicated for evaluation of respiratory symptoms (eg,

cough, wheezing, dyspnea, chest pain), bronchodilator therapy, effect of workplace
exposure to dust or chemicals, and disability. It can also be used to assess severity and
progression of lung diseases, such as asthma, chronic obstructive lung disease, and
various restrictive diseases. (See 'Introduction' above.)The major types of pulmonary
function tests (PFTs) include spirometry, lung volumes, and diffusing capacity. Other
PFTs include flow-volume loops (which record forced inspiratory and expiratory flow
rates) and measurements of maximal respiratory pressures. (See 'Pulmonary function
tests' above.)Forced expiratory volume in one second (FEV1) and forced vital capacity
(FVC) are the primary measurements obtained by spirometry. Their ratio (FEV1/FVC)
is important for distinguishing obstructive airways disease and restrictive disease. A
reduced ratio suggests obstructive airway disease and a normal ratio suggests restrictive
disease, if accompanied by reduced lung volumes. (See 'Spirometry' above.)Flow-
volume loops can identify upper airway obstruction, which can be impossible to detect
from standard FVC measurements. A characteristic limitation of flow (ie, a plateau)
during forced inhalation suggests variable extrathoracic obstruction, while limitation of
flow during forced exhalation suggests variable intrathoracic obstruction (figure 1).
Fixed upper airway obstruction causes flow limitation during both forced inhalation and
forced exhalation. (See "Flow-volume loops".)Spirometry before and after the
administration of a bronchodilator can be performed to detect bronchodilator
responsiveness. An increase in the FEV1 of more than 12 percent and greater than 0.2 L
suggests bronchodilator responsiveness; however, the lack of a bronchodilator response
should not preclude a therapeutic trial of bronchodilators and/or inhaled glucocorticoids.
(See 'Post-bronchodilator' above.)Measurement of lung volumes complements
spirometry. Common measurements include total lung capacity (TLC), functional
residual capacity (FRC), and residual volume (RV). Decreased lung volumes suggest
restrictive disease if accompanied by a normal FEV1/FVC ratio. Increased lung
volumes suggest static hyperinflation due to obstructive airways disease if accompanied
by decreased FEV1/FVC ratio. Coexisting restriction and obstruction can be detected,
but requires both spirometry and lung volumes. (See 'Lung
volumes' above.)Measurement of diffusing capacity for carbon monoxide (DLCO)
assesses gas exchange. Decreased DLCO accompanied by restrictive disease suggests
intrinsic lung disease, whereas normal DLCO accompanied by restrictive disease
suggests a non-pulmonary cause of restriction. Markedly decreased DLCO accompanied
by obstructive airways disease suggests emphysema, whereas normal or mildly
decreased DCLO suggests an alternative cause of obstructive airways disease. (See
'Diffusing capacity' above.)Measurement of maximal inspiratory and expiratory
pressures detects respiratory muscle weakness. Maximal inspiratory pressure (MIP) is
the maximal pressure that can be produced by the patient trying to inhale through a
blocked mouthpiece. Maximal expiratory pressure (MEP) is the maximal pressure
measured during forced expiration through a blocked mouthpiece after a full inhalation.
(See 'Maximal respiratory pressures' above.)Pulse oximetry is used to screen for oxygen
desaturation in patients with exercise limitation and to determine the adequacy of
supplemental oxygen therapy. A fall of more than 4 percent (ending at a saturation
below 93 percent) suggests significant desaturation, which can be confirmed with
arterial blood gas measurements. (See 'Oxygen desaturation during exercise' above.)

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