Body plethysmography

Dr Avneet Garg
 Introduction

History

Underlying Principles
• Lung volume
• Airway resistance
Outline Technical aspects

Indications/ contraindications/Hazards

Applications
• Routine
• Beyond routine
 • While spirometry is the most commonly used
method to assess lung function in clinical practice, at
times it is necessary to measure the volume of the
air that the lungs cannot displace (static lung
volumes)

Introduction • The word plethysmograph is derived from the

Greek plethusmos (enlargement)

• A plethysmograph is an instrument for measuring

changes in volume within an organ or whole body
(usually resulting from fluctuations in the amount of
blood or air it contains
How to measure TLC Airways Resistance
and RV?
• He dilution method • Provides useful information on airway
functions
• Nitrogen washout
• Body plethysmography
• Can be applied to various techniques –
• Bronchodilator response
• Bronchial Provocation Testing – Histamine,
Mannitol etc
• Pre & Post surgery for upper airway
disorders

• Various Techniques –
• Impulse Oscillometry
• Body Plethysmography
 History 1
1790 Menzies - Dissertation on Respiration
• Plunged a man into water in a hogshead up
to his chin and measured the rise and fall
of the level in the cylinder round the chin

• With this method of body

plethysmography he determined the tidal
volume
 History 2
• 1868 - Bert P: Total Body Plethysmography.
• Experiments with animals in a closed total body
plethysmographic system.
• Presented his studies to the ‘Société de Biologie’ under
the title
‘Changement de pression de l’air dans un poumon
pendent les deux temps de l’acte respiratoire’
['Alterations of the pulmonary air pressure during the two
periods of respiration’]

• He did not do spirometric measurements together with

the plethysmography, nor did he do plethysmographic
measurements on humans.
 History 3
• Dubois et al 1956
• Forms the basis of constant-volume
plethysmography in use today for lung
volume and airway resistance
measurements

DuBois, AB, Botelho, SY, Bedell, GN, Marshall, R,

Comroe (Jr), JH.
• A rapid plethysmographic method for measuring
thoracic gas volume: a comparison with a nitrogen
washout method for measuring functional residual
capacity in normal subjects. J. Clin. Invest. 1956.
35:322-326
Underlying Lung volume
Principles Airway resistance
Apparatus

• The volume-constant whole-body plethysmograph

• is a chamber resembling a glass-walled telephone
box in shape and volume (about 700- 1000 L)
• During measurement the box is closed with an
airtight seal, except for a small controlled leak that is
used to stabilize the internal pressure by allowing for
equilibration of slow pressure changes

• Pressure transducer
• 1. serves to measure the pressure inside the box
relative to ambient pressure
• 2. placed close to the mouth for recording mouth
pressure during a shutter maneuver.

• The shutter mechanism

• can be used to deliberately block the airflow by
transient occlusion.

• Respiratory flow rate is recorded by pneumotachograph,

anemometer, or ultrasound measurement, all of which is
calibrated via syringes delivering a defined volume.
Boyles Law
• Based on Boyle’s law -
PV = k
• Assumes temperature remains constant
• When subject breathes in and out
against a shutter, changes in pressure
and volume occur
 • When inspiration from the end-expiratory lung volume is
initiated by inspiratory muscles, thoracic volume
increases.

• The increase in lung volume is identical to that of thoracic

volume, as the intrathoracic organs are incompressible.
Definition of
• However, the airflow into the lung does not start
shift volume immediately, since building-up of a pressure gradient is
required to induce mass movement. Why?

• The decrease of pressure in response to the volume

change would follow the law of Boyle-Mariotte, as the
compartment would be closed.

C.P. Crie´e et al, Respiratory Medicine 2011

 • Airflow always tends to reduce pressure differences until
equilibrium is reached.

• During inspiration, however, the continuing inspiratory

movement of the thorax ensures that its volume
excursion is slightly ahead of the equilibrating mass flow.

Definition of • When the thoracic, i.e. lung volume ceases to increase,

alveolar and box pressure will rapidly reach equilibrium.
shift volume
• As long as air is flowing, the increase in lung volume is
slightly greater than the volume of air that has passed
through the airways into the lung.

• This small difference represents a lag in mass flow during

the breathing cycle and is called “shift volume”
 • This allows the determination of two primary measures:
• thoracic gas volume
• specific airway resistance

• Both measurements rely on the fact that the volume

Definition of defect within the lung represented by the shift volume is
necessarily equal in magnitude but opposite in sign to a
shift volume volume defect in the body box.

• Thus, the shift volume in the box is the mirror image of

the shift volume of the lung.
 According to Boyle-Mariotte’s law
• the unknown volume of a closed compartment can
be determined
Assessment of • if absolute changes of volume can be induced
• relative changes in pressure can be measured.
thoracic gas
volume • Determination of TGV would be possible if
• the lung could be treated as a closed compartment
• one could measure the changes in alveolar pressure
• parallel changes in volume.
(Pmouth) equals Palv according to Pascals Law
Determination of Intrathoracic gas volume (ITGV)

Since shift volume (the amount of compression and decompression)

and alveolar pressure change are proportional to each other, the result
is a linear relationship between mouth occlusion pressure on one hand
and shift volume or box pressure on the other hand
C.P. Crie´e et al, Respiratory Medicine 2011
 • Resistance is defined as the ratio of driving
Assessment of pressure to flow.

airway • The more pressure is needed for a given flow,

resistance the greater the resistance.
 Before shutter closes

As the inspiration starts,

Airflow starts and tend to thorax volume increases with
reduce pressure differences decrease in pressure and no
until equilibrium is reached flow at mouth
‘Shift Volume’
 Specific airway resistance

• Specific airway resistance (sRaw) is the ratio of shift

volume, or equivalently box pressure, to flow rate,
expressed in suitable units

C.P. Crie´e et al, Respiratory Medicine 2011

• A more flat curve indicates an elevated shift volume relative to airflow and thereby an
increase of sRaw..

• Only in normal subjects breathing loops are straight lines.

• Obstructive diseases, however, not only lead to a flattening of the loop but also alter its form.

Schematic representation of specific resistance loops

in
a) a normal subject
b) a subject with increased large airway resistance
c) a subject with chronic airflow obstruction
d) A subject with upper airway obstruction.

C.P. Crie´e et al, Respiratory Medicine 2011

 • Correspondingly the ratio of shift volume to flow
Determination rate, representing sRaw, can be transformed into
that of alveolar pressure change to flow rate, which
of airway is just airway resistance, Raw.

resistance and • Mathematically equivalent to dividing sRaw by

FRCpleth as determined in the occlusion maneuver
its relation
to sRaw • Therefore Raw is the ratio of sRaw to FRCpleth
Technical aspects
Start up ..
 Procedure
• The equipment should be turned on and allowed an adequate
warm-up time.

• The equipment is set up for testing, including calibration,

according to manufacturer’s instructions.

• The equipment is adjusted so that the patient can sit

comfortably in the chamber and reach the mouthpiece without
having to flex or extend the neck.

• The patient is seated comfortably, with no need to remove

dentures. The procedure is explained in detail, including that
the door will be closed, the patient’s cheeks are to be
supported by both hands, and a nose clip is to be used.

• The plethysmograph door is closed, and time is allowed for the

thermal transients to stabilize and the patient to relax.
Procedure

• The patient is instructed to attach to

the mouthpiece and breathe quietly
until a stable end-expiratory level is
achieved

• sRAW is measured at that point

• Hence sRAW measurement does not

need any occlusion or forced
maneuver
Procedure

• Patient is instructed to perform a series of

gentle pants at a frequency between 0.5 and
1.0 Hz .

• When the patient is at or near FRC, the

shutter is closed at end-expiration for 2–3 s.

• A series of 3–5 satisfactory panting maneuvers

should be recorded

• After which the shutter is opened.

• 2 ways to continue the measurement after

last occlusion
Procedure
• 2 ways to continue the measurement
after last occlusion maneuver.

• If possible, the patient should perform a

maximal expiration to determine ERV
without potential for intermediate shifts
in FRC. This should be followed by a
maximal inspiration to determine IVC.

• Patients with severe dyspnea may have

difficulty performing the preferred VC
method

• Alternative is take 2 or 3 tidal breaths

after the panting maneuver
Criteria of acceptability
• Maneuver shows a closed loop
without drift
• Tracing does not go off the screen
• Breathing is at 0.5 – 1 Hz
• At least 3 TGV values should agree
within 10% and the mean value
reported
SUMMARY OF PROCEDURE
 • Body plethysmographic determination of VTG, Raw and
sGaw
• Diagnosis of restrictive lung diseases
• Measurement of lung volumes to distinguish between
restrictive and obstructive processes
• Evaluation of obstructive lung diseases, such as bullous
emphysema, which may produce artifactually low results
if measured by helium dilution or N2 washout method.
Indication • Estimating trapped gas (i.e., FRC plethysmograph).
• Evaluation of airway resistance
• Determination of response to bronchodilators, as
reflected by changes in Raw, sGaw.
• Determination of bronchial hyper reactivity in response
to methacholine or histamine
• Following the course of disease and response to
treatment.
 • Mental confusion, muscular incoordination,
body cast or any other condition that prevent
the patient from entering the box.

Contra- • Claustrophobia.
indications
• Presence of devices or other condition that
interfere with pressure changes (e.g chest tube,
Trans tracheal O2 catheter, or rupture ear
drum).
 • Improper panting technique for VTG and Raw
measurements may results in excessive
intrathoracic pressures causing syncopal
attacks.

• Hypercapnia or hypoxia, if prolonged

confinement in chamber. Needs to opened
Caution periodically.

• Infection transmission risk via improperly

cleaned equipment i.e. Mouthpiece or as a
conseqence of the inadverent spread of droplet
nuclei or body fluids( patient to patient or
patient to technologist)
Body Plethysmography

Advantages Disadvantages

• Rapid method of multiple • Expensive equipment

estimations of VTGV • Few reference values
• Good repeatability • Claustrophobia
• Raw and SGaw obtainable
• Measures all gas within thorax
 Clinical role
• Diagnosis of restrictive lung
disease
• For measurement of lung
volumes to distinguish
between restrictive and
obstructive processes.
Restrictive disorders
• Assessment of TLC
is considered indispensible in the
diagnosis of restrictive disorders,
which are defined as TLC being
below the 5th percentile of normal
values.
Obstructive disorders
• The determination of RV and RV/TLC
also allows to judge upon the degree
of lung hyperinflation.
• Values of RV or a ratio RV/TLC above
the 95th percentile but below 140%
predicted are indicative of mild,
values between 140 and 170%
predicted of moderate, and values
above 170% predicted of severe
hyperinflation
Voulmes RV/TLC RV TLC VC
65-135% 80-120% >90%
Patients value Increased 229% 107% 50%

AIR TRAPPING
Response of Bronchodilators
• Bronchodilator testing,
• Spirometry might underestimate the response.
• Body plethysmography is capable of detecting bronchodilator responses that would be false
negative when solely relying on spirometry.
• A reduction of Raw or sRaw by 20% suggests partial reversibility, and changes by 50% indicate
reversibility with certainty.
• Serial measurements of sRaw also allow documentation of the time course of bronchodilation,
i.e. onset of drug effect.

• It also seems advantageous in specific provocation tests with inhaled allergens, as bouts of
coughing after allergen inhalation often do not allow to conduct a valid spirometry in time.
• The provocation test could be considered as positive when specific airway resistance (sReff) has
doubled and at the same time increased to 2.0 kPa s as a minimum value.
• Other criteria have also been used, such as a 35 or 40% fall in specific airway conductance
(sGaw) which is the reciprocal value of sRaw.

• Pellegrino R, Wilson O, Jenouri G, Rodarte J. Lung mechanics during induced bronchoconstriction. J Appl Physiol 1996;81:964e75.
• Criee CP et al. Body plethysmography e Its principles and clinical Use. Respiratory Mechanics 2011;105:959-971
Calculation of trapped air
• There is a difference between the lung volume measured via the helium-dilution technique
and that measured via body plethysmography.
• The helium-dilution technique may underestimate the exact volume of gas in the lung
because of inadequate time to equilibrate with slowly communicating and
noncommunicating air spaces such as bullae.
• However, lung volume can be more accurately measured and should be measured in these
cases, with body plethysmography, which measures the total volume of the thorax.
• In fact, the difference in TLC between the 2 techniques (body plethysmography minus
helium-dilution) approximates the volume of the bullae.

Agarwal R , Aggarwal AN. Bullous Lung Disease or Bullous Emphysema? Respiratory Care 2006;51(5):532-534
Lung volume
reduction
surgery
LUNG VOLUME REDUCTION SURGERY

 Current guidelines recommend the use of Body

Plethysmography for the measurement of lung volumes
 Measures all lung volume within the chest, not just that
which is accessible through gas dilution techniques

PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 5 2008

Tracheal stenosis
• Post-intubation tracheal stenosis usually involves Invasive diagnostic methods such
as fiberoptic or rigid bronchoscopy for initial assessment and treatment.
• This study aimed to evaluate plethysmography as an alternative diagnostic tool for
post-intubation tracheal stenosis
• 30 patients who were admitted to ICU during 1 year were diagnosed with post-
intubation tracheal stenosis. All patients underwent plethysmography and rigid
bronchoscopy
• Stricture intensity had the strongest correlation with upper airway resistance
(p = 0.001).
• The relationship of length of stricture to FEV1 and MEF 50 and 75 was significant in
univariate analysis, and to reserve volume and TLC in multivariate analysis.
• Severity of stricture directly related to sRaw
Jamaati HR et al ,Evaluation of plethysmography for diagnosis of postintubation tracheal
stenosis. Asian Cardiovascular and Thoracic Annals April 2013 21: 181-186
Tracheal stent response
• Assess airway function by use of airways resistance measurements before and after
stenting and to follow progress of patient over time
• Raw is more comfortable for the patient to perform
• Stent should decrease Raw as radius of airway becomes greater.
• FEV1 should also increase and shape of F-V curve should be more normalized
Take Home Message

 Body Plethysmography technically demanding, physiologically nontrivial, highly

informative, non-invasive method to obtain information on airway obstruction
and lung volumes that is not available through spirometry

 Airways resistance provides a useful measure of airway dysfunction and can be

used in relation to dynamic lung volumes to further assess airway dysfunction

 Body plethysmography provides a more accurate reflection of the true size of the
lungs at RV, FRC and TLC than gas dilution techniques, especially in AWO.