BODY PLETHYSMOGRAPHY

Adrian H Kendrick BA, PhD, PgD, RPGST

Consultant Clinical Scientist
Department of Respiratory Medicine
University Hospitals, Bristol, England

DECLARATIONS

The presenter has no conflicts of interest

Where drug names are used, these relate to those

used in peer-reviewed publications quoted within
this presentation

Pictures of equipment within this presentation are

used to illustrate aspects of the presentation and
should not be represented as an endorsement by
the presenter of the equipment shown
2

OUTLINE OF TODAY
What

do we need to measure?
History of Body Plethysmography
Underlying Principles

Constant Volume - Lung Volumes/Airways Resistance

Variable Volume - outline

Technical

Issues
Applications
Routine Applications
Beyond Routine

Summary

and Conclusions

WHAT
4

DO WE NEED TO MEASURE?

LUNG VOLUMES

WE CAN MEASURE

EASILY
Simple Spirometry

WHAT

WHAT

WE CAN MEASURE
Index

Usefulness

Vital Capacity

Useful marker for the effect of

disease and assessing outcomes
from exercise (6MWT)

Expiratory Reserve Volume

Effects of obesity on lung volumes,

particularly where BMI > 35 kg.m-2

Inspiratory Capacity

Marker of BD response where FEV1

shows no significant change
effects of BD on hyperinflation

WHAT

WE CANNOT MEASURE SO EASILY

WHAT

WE CANNOT MEASURE
Index

Usefulness

Total Lung Capacity

Marker of effects of obstructive airways

disease and key index to confirm the
presence of a restrictive ventilatory defect

Functional Residual Capacity

Marker of hyperinflation and reflects

changes in PV relationships of chest wall
and/or lungs.
FRC/TLC ratio reflects the degree of
hyperinflation

Residual Volume

Marker of gas trapping.

Reflects the effects of obstructive or
restrictive disease on lung volumes.
RV/TLC ratio reflects poor gas mixing and
hence gas trapping
9

HOW

TO MEASURE

TLC

AND

RV?

Use FRC to obtain measurements Multi-breath He dilution measurement

Nitrogen washout
Body plethysmography
Use TLC only
Single-breath He/CH4 measurement (TLco) - VA
Radiographic CXR and/or CT

10

AIRWAYS RESISTANCE
Provides useful information on airway functions
Can be applied to various techniques

Bronchodilator response
Bronchial Provocation Testing Histamine, Manitol etc
Pre & Post surgery for upper airway disorders

Various Techniques
Impulse Oscillometry
Body Plethysmography

11

BRIEF HISTORY OF BODY

PLETHYSMOGRAPHY
12

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

13

HISTORY - 2
1868 - Bert P: Total Body Plethysmography.
Experiments with animals in a closed total body
plethysmographic system.
Presented his studies to the Socit de Biologie under
the title Changement de pression de lair dans un poumon
pendent les deux temps de lacte 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.
14

MODERN BODY PLETHYSMOGRAPH - 1

Dubois et al 1956
Most quoted couplet of papers in JCI ever!
Forms the basis of constant-volume plethysmography
in use today for lung volume and airway resistance
measurements

15

MODERN BODY PLETHYSMOGRAPH - 2

Diagram of the apparatus for measuring lung volume.

B, body plethysmograph; S, shutter which occludes airway; L, lung; C, capacitance
manometer to record pressure changes in the plethysmograph (which are proportional to
the change in body volume); P, capacitance manometer to record pressure changes in
the mouth (which are equal to alveolar pressure when there is no airflow); O, cathode ray
oscillograph with x and y axes.
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.

16

MODERN BODY PLETHYSMOGRAPH - 3

Diagram of the apparatus for measuring airways resistance.

DuBois, AB, Botelho, SY, Comroe (Jr), JH. A new method for measuring airway resistance in man
using a body plethysmograph; values in normal subjects and in patients with respiratory disease. J.
Clin. Invest. 1956. 35:327-335.

17

18
DuBois, AB. Airway resistance. Am. J. Resp. Crit. Care Med. 2000. 162:345-346.

MEAD BODY PLETHYSMOGRAPH

19

Mead J. Volume displacement body plethysmograph for respiratory measurements in human subjects
J Appl Physiol 1960; 15: 736 - 740

BODY PLETHYSMOGRAPHS TODAY

20

ADULTS

21

CHILDREN

22

CHILDREN

23

ANIMALS

24

TYPES
25

OF

BODY PLETHYSMOGRAPH

CONSTANT VOLUME & VARIABLE VOLUME

Dubois

Mead Original

Mead Modern
26

CONSTANT VOLUME
Dubois Type
Subject sealed inside the box
Box volume 700 litres
Subject breathes from within the box
Pneumotachograph (pn) records flow
Shutter (S) occludes airway/breathing
Changes in mouth pressure recorded directly
Changes in box volume recorded as changes in box
pressure

27

VARIABLE VOLUME - 1
Mead Type Box
Patient breaths from outside the box
Volume changes recorded with a
water-filled (Krogh-type) spirometer
Mouth pressure recorded directly
Flow at mouth recorded outside the
box using pneumotachograph (pn)
Shutter (S) occludes airflow

28

VARIABLE VOLUME - 1
Mead Type Box modern update
Patient breaths from outside the box
Volume changes recorded with a
wall mounted pneumotachograph
Mouth pressure recorded directly
Flow at mouth recorded outside the
box using pneumotachograph (pn)
Shutter (S) occludes airflow

29

WHICH BOX

FOR

WHAT?

Constant Volume

Variable Volume

Static Lung Volumes

Dynamic Lung Volumes
Airways Resistance

Static Lung Volumes

Dynamic Lung Volumes
Airways Resistance
Compliance measures
Gas compression studies

30

WHICH

IS

EASIER

TO

USE?

Constant Volume

Variable Volume

Easy to calibrate
Simpler measures can
be made using
computerized systems

Fun to calibrate!
More difficult to make
measurements
limited software, better
measurements made
by hand

31

PRINCIPLES OF LUNG VOLUME

MEASUREMENTS USING A BODY
PLETHYSMOGRAPH
32

PRINCIPLES
Based

on Boyles law PV = k
Assumes temperature remains constant
When

subject breathes in and out against a

shutter, changes in pressure and volume occur

33

BOYLES LAW

34

LUNG VOLUMES
Boyles

Law: for fixed mass of gas at constant

temperature: P1V1 = P2V2

Brief

occlusion at airway opening to seal a fixed

mass of gas in the lungs (V1) - i.e. the FRC to
be measured

Pressure

within lungs at end expiration (P1) ~

atmospheric pressure.

P2

and V2 represent the pressure and volume

in the lungs after a respiratory effort against the
occlusion.
35

LUNG VOLUMES
Thus PV

= (P + P).(V - V)
= V(P - P) + (P - P) V
= PV - VP + (P - P) V

Re-arranging PV = (P - P) V
VL
= (P - P)(V/P)
P is such a small fraction of P (barometric pressure)
that it can be omitted without loss of accuracy
VL
= P(V/P)
36

CONSTANT VOLUME BODY - BOX

37

THE CONSTANT VOLUME BOX

38

Specifications and Calibration

KEY FACTORS
In tidal breathing, the chamber pressure changes
are small, only a few hPa (or cmH2O).
Disturbances may be caused by

Patient-related temperature increase within the chamber

(body heat),
Breathing-related air temperature and humidity changes
Pressure changes related to external pressure variations

To attain adequate pressure equilibration between

mouth and alveolar space, panting during the
shutter manoeuvre should be avoided
39

CONSTRUCTION
The characteristics of the body plethysmograph
chamber are key to ensure good measuring quality.
Some of the features are:

Rigidity of the enclosure

Heat transfer characteristics of the chamber walls
Built-in equilibration vessel
BTPS compensation
Calibration unit
Adjustment of a defined leak
Type and speed of the shutter assembly
40

PATIENT SYSTEM
Bacterial Filter

Shutter
Mechanism

Pneumotachograph
41

CONSTANT VOLUME BODY - BOX

Characteristics

of the constant volume body

box need to be accounted for
Volume changes are recorded in terms of
pressure changes. This needs to be calibrated
Pump air into the box - 50ml sinusoidal pump
with box sealed and record deflection
VL
= PB(V/P). Cbox = VTGV
where PB is the barometric pressure and Cbox
is the box calibration factor
42

CONSTANT VOLUME BODY - BOX

TGV

is thoracic gas volume. This is the total

volume of compressible gas in the thorax, and
will include any compressible gas in the
stomach and abdomen
TGV will be higher than FRC in normal
subjects due to this difference and the fact
that the shutter may not close at exactly FRC

43

BODY BOX SPECIFICATIONS

Box

must be airtight
All pressure transducers should be calibratable
with a known pressure
Volume calibration with a 3 or 7 litre calibration
syringe
Time constant for leaks tested daily

44

INTERNATIONAL

GUIDELINES

45

BODY BOX SPECIFICATIONS

Item

Specification

Mouth Pressure range

Accuracy

-2 to +2 kPa
0.01 kPa

Plethysmograph
Pressure range
Accuracy

At least 0.02 kPa

5 x 10-5 kPa

Volume deflection
Accuracy

-200 to +200 ml
0.5 ml

P and V

In phase up to 10 Hz

46

CALIBRATION
Mouth pressure is verified with a
mercury or water barometer
Flows are verified with a rotometer
(flow-metering device) or a 3-liter
syringe
Box pressure is calibrated by using
a sine-wave rotary pump that
simulates changes in the
inspiratory and expiratory volumes

47

BODY BOX - CALCULATIONS

Information required Barometric pressure
Volume of box
Subjects mass (kg)
Angle of deflection
Box pressure calibration
Mouth pressure calibration

- PB
- Vbox
-W
-
- Boxcal
- Pcal

48

EFFECTS

OF

BODY WEIGHT

When a patient sits inside the box, their body mass

displaces air from within the box
The density of human flesh etc is 1.07 that of air
Therefore need to adjust the volume of the air
within the box for the mass of the human

Wcorr = (Vbox - W/1.07)/Vbox

Alternatively calibrate the box with the patient

inside it.
49

BODY BOX - CALCULATIONS

VL = PB(V/P). Cbox = TGV
TGV = (Boxcal/Pcal) x (PB-47) x Wcorr x 1.33 x Tan -1
RV = TGV - ERV
TLC = RV + IVC
or
TLC = TGV + IC
RV = TLC - EVC
50

CALCULATION

OF

TANGENT

51

52

ACCURACY

OF MEASUREMENTS

Duplicate measurements of TGV should be within

5% for a skilled operator and good coaching of the
patient
Different operators, assessing the same patient
should get similar accuracy, but slight variations in
techniques and encouragement may reduce the
accuracy
Computer software generated line plots MUST
always be verified by the operator and adjusted if
required.

53

CONSTANT VOLUME BOX

54

Procedure

CONTRAINDICATIONS

FOR

BOX TESTING

Preventing Patient entering the box

Mental confusion
Poor muscular co-ordination
Body cast
Wheelchair
Claustrophobia
Extreme Obesity

Presence of devices - continuous I.V. infusion

Conditions that interfere with pressure changes

Chest tube
Trans-tracheal O2 catheter
Ruptured ear drum.

Continuous O2 therapy that cannot be removed

55

http://www.artp.org.uk/en/patient/lung-function-tests/lung-volumes.cfm
56

PROCEDURE
Seat

subject upright in box, seal door and

allow subject to temperature equilibrate within
the box ( - 2 mins)
Vent the box to release any pressure build up
due to thermal changes
When equilibrium occurs, Boyles law applies
Attach subject to mouthpiece, apply noseclip
and place flats of hands on sides of face and
under chin
57

PROCEDURE

BEFORE SHUTTER CLOSES

Situation

at end expiration, prior to any

respiratory efforts against an occlusion valve

58

PROCEDURE
During

tidal breathing, close shutter at FRC

and ask subject to breath in and out gently
against the shutter an open glottis at a rate of
0.5 - 1 Hz (30 60 breaths/min)
After 1 to 2 breaths against the shutter, open
shutter and ask subject to breathe fully out
(ERV) and then fully in (IVC) and then breathe
normally
Release vent, seal box and repeat, obtaining
3 technically acceptable traces are obtained 59

PROCEDURE SHUTTER OCCLUSION

During inspiratory efforts against the occlusion

As lung volume increases,
box volume decreases and
box pressure increases

As lung volume
increases, alveolar
pressure decreases
and hence pressure
at mouth decreases
P1 -P

Changes in box pressure

calibrated in terms of volume
using a calibrated syringe
60

SUMMARY

OF

PROCEDURE

61

VISUAL DISPLAY

62

Body Plethysmography

Advantages

Disadvantages

Rapid method of multiple

estimations of VTGV
Good repeatability
Raw and SGaw obtainable
Measures all gas within
thorax

Expensive equipment
Few reference values
Claustrophobia
Inaccurate in severe airflow
obstruction

63

CRITERIA OF ACCEPTABILITY
Manoeuvre shows a closed loop without drift
Tracing does not go off the screen
Breathing is at 0.5 1 Hz
Tangents should be within 10%
At least 3 TGV values should agree within 5% and the
mean value reported

64

PRINCIPLES OF AIRWAYS
RESISTANCE MEASUREMENTS
65

AIRWAY RESISTANCE - PHYSIOLOGY

0.010
0.009

Resistance (SIUnits)

0.008
0.007
0.006
0.005
0.004
0.003
0.002
0.001
0.000
0

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Airway Generation

66

AIRWAY RESISTANCE - PHYSIOLOGY

Cumulative Resistance (% of total)

100

80

60

40

20

0
0

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Airway Generation

67

AIRWAY RESISTANCE - PHYSIOLOGY

R1

R2

R3

SERIES
RTOT =

0.01

0.02

R1

= 0.01

R2

= 0.01

+ 0.03

= 0.06 units

PARALLEL
1/RTOT =
RTOT =

1/ 0.01 + 1/0.01 = 200

0.005 units

68

RESISTANCE

Electrical

Lungs

V P
R

I
V
Ohms Law

69

AIRWAYS RESISTANCE
Resistance

to airflow in the upper airways and the

tracheobronchial tree
Changes in airways resistance may be useful in
assessing response to interventions
Newer techniques may be able to assess both the
upper airways and changes in the peripheral
airways during tidal breathing
70

RESISTANCE & MEASUREMENT

Pleural Space
Chest Surface

Sum

Rtotal

0.02
0.02
0.12
0.26

Forced Oscillation

Alveoli

0.05

Oesophageal balloon

2-3mm Airway

0.05

Interupter

Larynx

Glottis
Raw (large)
Raw (small)
Rti
Rth

R(SI)
Plethysmography

Mouth

71

AIRWAY RESISTANCE - BOX

Record

airflow against
box pressure with shutter
open
Record mouth pressure
against box pressure
with shutter closed

72

AIRWAY RESISTANCE - BOX

Shutter Closed; Box sealed
Recording of Mouth pressure versus
Box Pressure as subject breathes
against the shutter
Mouth Pressure

Airflow

Shutter Open; Box sealed

Recording of Airflow from
pneumotachograph versus
Box Pressure.

Box Pressure

Box Pressure

73

AIRWAY RESISTANCE - BOX

PBo x PAl v PAl v

x

R Aw
V PBo x
V

Tan
k
Rc RAw
Tan
74

AIRWAY RESISTANCE - BOX

GAW

= 1/RAW

SGAW= GAW/TGV

75

AIRWAY RESISTANCE & LUNG VOLUME

TLC

25

RV
0.2

FRC

0.1

TLC
0.0

Airway Conductance (SI Units)

Airway Resistance (SI Units)

0.3

20

15

FRC

10

RV
0

Lung Volume (litres)

Lung Volume (litres)

76

PHYSIOLOGICAL MATHS!

76
77

PHYSIOLOGICAL MATHS!
r
r4
R1

= 0.75
= 0.3164
= 3.16V

P
R1

= 2.5
= 3.16
= 0.79

r
r4
R2

= 0.375
= 0.0198
= 50.57

P
R2

= 2.5
= 50.57
= 0.049

R2 R1 = 16

Flow by 94%
77
78

DETERMINANT OF RESISTANCE
Laminar

and Turbulent Flow

Airway diameter/x-sectional area (A)
Gas Density () and Viscosity ()
Reynolds Number

79

FLOW

IN

TUBES

80

DETERMINANT

OF

RESISTANCE

< 100 laminar flow

Rn > 10,000 turbulent flow
Rn ~ 1500 trachea
He/O2 vs N2/O2 vs SF6/O2
Rn

81

AIRWAY RESISTANCE MEASUREMENTS

Assessing Reversibility of inhaled drugs

Effect of bronchoconstrictor agents
Large and small airway function
Monitoring

changes in disease
82

EFFECTS

OF

DISEASE

0.6

Airway Resistance (kPa.l-1.s)

0.5

0.4

0.3

0.2

0.1

0
Normal

Mild Airflow
Obstruction

Emphysema Asthma Pre - Asthma Post

BD
- BD
83

TECHNICAL ISSUES FOR BODY

PLETHYSMOGRAPHIC
MEASUREMENTS
84

TECHNICAL

ISSUES

Shift Volume
Inaccuracy of Measurements in AWO
Linked and Unlinked spirometry
Panting frequency
Abdominal Gas Volume

85

SHIFT VOLUME
This is the change in volume within the lungs in
relation to the change in box pressure used as a
surrogate marker of changes in volume.
As the subjects breathes against the shutter, the
lung volume changes, so the box pressure
changes.
By calibrating the box pressure for volume change,
the actual change in volume the shift volume can
be estimated
The shift volume is useful in assessing the effects
of disease on resistance

86

SHIFT VOLUME

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) and
87
a subject with upper airway obstruction.

INACCURACY

IN

AWO

A number of papers have demonstrated that body

plethysmography can over-estimate TGV and hence
TLC in patients with asthma and severe AWO.
The major assumption in the technique is that Pmouth is
the same as PAlv and this is effectively true in normal
subjects and in patients with mild airflow obstruction.
In moderate to severe airflow obstruction, there is a time
lag between Pmouth and PAlv due to the characteristics of
the airways resulting in an underestimation of PAlv and an
overestimation of TGV
To overcome these issues, slow panting/breathing
88
against the shutter is advised

PANTING FREQUENCY
In AWO, there is a delay between alveolar pressure
and mouth pressure out of phase with each other
This results in an overestimation of TGV and hence
TLC
This artefact is exacerbated when

Airways are very narrow (Raw)

Very compliant airways
High panting frequency

Panting/breathing at < 1Hz allows more time for

mouth and alveolar pressures to equalize, thereby
reducing the phase differences

89

DIFFERENCES

IN

TLC

IN

CHRONIC AWO

D iff e r e n c e ( T L C m - T L C e s )

1 .6
1 .4
1 .2
1 .0
0 .8
0 .6
0 .4
0 .2
0 .0
0 .0 2

0 .0 4

0 .0 6

- 0 .2

S G aw cm H 2O

-1

sec

0 .0 8

0 .1 0

-1

Rodenstein & Stanescu Am Rev Respir Dis 1982; 126: 1040 - 1044

90

LINKED

AND

UNLINKED SPIROMETRY

TLC and RV are calculated as

TLC = RV + VC = FRC + IC
RV = FRC ERV = TLC VC
Does it matter if the VC manoeuvre is done immediately
after the shutter opens or using a different device?
Purist approach linked as FRC may change between
manoeuvres
Acceptable alternative - unlinked

91

UNLINKED

AND

UNLINKED SPIROMETRY

Mean SEM

92
Williams & Bencowitz. Differences in plethysmographic lung volumes. Chest 1989; 95: 117 - 123

ABDOMINAL GAS VOLUME (AGV)

accounts for about 115 ml1
The effects of AGV may be dependent on level
of panting. FRC appears to be the best level to
pant at2
TGV may be lower by 900 ml if the subject
pants using diaphragm and abdominal muscles
rather than intercostal and accessory muscles3
AGV equates to about 360 ml3
AGV

1.

2.
3.

Bedell et al 1956
Brown et al, 1978
Habib & Engel, 1978

93

BODY

PLETHYSMOGRAPHY
VERSUS OTHER TECHNIQUES
94

AGREEMENTS

OF

METHODS

In Normal subjects VA and TLCHe agree ~ 300 - 400 ml

VA and TLCBox agree ~ 400 - 500 ml
TLCBox and TLCHe agree ~ 300 400 ml
Similar

results observed in patients with mild airflow

obstruction and in restrictive ventilatory defects
95

AGREEMENTS
Moderate

Note:

OF

METHODS

to severe airflow obstruction

TLCBox > TLCHe > VA

if TLCBox > VA by 3+ litres

then emphysematous bulla may be present

96

WHY

DIFFERENCES IN

TLC

MEASURES

97

DIFFERENCES

IN

TLC & VA
TLCHe - VA

T L C p le t h - V A

TLCx

- V A ( lit r e s )

0
0

20

40

60

80

F E V 1 % p r e d ic t e d

Data from T Goddard, ERS 2011 with permission

100

120

140

98

GAS DILUTION NORMAL/RESTRICTIVE

Model 1

1min
75%

2min
20%

5 min
5%

In 1 minutes, 75% of the lung volume will be measured

In 5 minutes, 100% of the lung volume will be measured

99

GAS DILUTION SEVERE AWO

Model 2

5min

20min

65%

25%

30min
10%

In 5 minutes, 65% of the lung volume will be estimated

In 10 minutes, 80% of the lung volume will be measured

100

BODY BOX ANY

Model 3

1min
75%

PATIENT!

+ Xml

2min
20%

+ Xml

5 min

5min

20min

5%

65%

25%

30min
10%

In 15 seconds all the lung volume will be estimated

101

INTERPRETATION
102

OF

RESULTS

ATS/ERS INTERPRETATION STRATEGY

103

ATS/ERS INTERPRETATION STRATEGY

Uses Standardized Residuals for each index to
assess the Lower Limit of Normal (LLN)
Based on physiologically and statistically sound
approach to interpretation of lung function
ATS/ERS guidelines do not state which test of lung
volumes Body plethysmography, Helium Dilution
or Nitrogen washout should be used within the
interpretation strategy.

104

Interpretation of Results
In patients with obstructive diseases
airway closure occurs at an abnormally high lung volume

FRC (functional residual capacity)

RV (residual volume)

Patients with reduced lung compliance (e.g., diffuse

interstitial fibrosis)
stiffness of the lungs + recoil of the lungs to a smaller resting
volume

FRC
RV

105

CLINICAL APPLICATIONS &INTERPRETATION

FRC

Gas trapping due to intrathoracic airway obstruction

Cystic lung disease

FRC

Abnormal alveolar development

Reduced recoil of chest-wall

Decreased lung compliance

Atelectasis
106

OBSTRUCTIVE LUNG DISEASE

107

EMPHYSEMA: PRESSURE-VOLUME CURVES

108

LUNG VOLUME REDUCTION SURGERY

109

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

110

RESULTS

OF

LVRS

111
Gerald M. OBrien; Satoshi Furukawa; Anne Marie Kuzma; Francis Cordova; Gerard J. Criner. CHEST 1999; 115:7584

RESIDUAL

VOLUME

(RV)

Normally it accounts for about 25% of TLC.

Limited by chest wall compression
RV increased
in airway narrowing with air trapping (Asthma)
in loss of elastic recoil (Emphysema).
RV decreased
Increased elastic recoil (pulmonary fibrosis)

112

TIDAL

VOLUME

(TV)

Equates to about 7ml/kg

400-700 ml
TV increased
Severe AWO + reduced breathing frequency
TV decreased
in severe RLD, + increase in breathing frequency

113

TOTAL LUNG CAPACITY (TLC)

It is the total volume of air within the lung after
maximum inspiration.
TLC is limited by lung compliance
TLC Increased
in airway narrowing with air trapping (Asthma)
in loss of elastic recoil (emphysema).
TLC Decreased
in ILD, muscle weakness, Obesity etc

114

EXPIRATORY RESERVE VOLUME

ERV reduced
Obesity (BMI > 35 kg.m-2)
ILD

115

INSPIRATORY

CAPACITY

(IC)

It is the maximal volume of air inspired from resting

expiratory level
Useful marker of de-hyperinflation after BDs

116

FUNCTIONAL RESIDUAL CAPACITY (FRC)

It is the volume of air remaining in the lungs at the end
of resting (normal) expiration.
Balance of chest wall and lung compliances
FRC Increased (>+1.65 SR) in
Emphysema (decreased elastic recoil)
Asthma
Bronchiolar obstruction (air trapping)
FRC decreased (< 1.65 SR) in
intrinsic ILD
by upward movement of diaphragm (obesity, painful
thoracic or abdominal wound)

117

VITAL CAPACITY

volume of gas measured on complete expiration

after complete inspiration without effort

Decreased in
Obstructive Lung Disease
ILD, Muscle weakness, Obesity etc
Note
If VC < 15 ml/kg and VT < 5ml/kg, patient needs
ABGs and overnight oximetry as this indicates likely
need for non-invasive ventilation

118

FEV1
FVC
FEV1/FVC
RV
TLC
RV/TLC
VC
FRC
FRC/TLC
FEV1/TLC

AWO

RLD (Lung)

RLD (non-Lung)

or N

N or

N or

N or

N or

N or
N

N or
N

N or
N
119

INTERPRETATION OF AIRWAYS
RESISTANCE
120

INDICATION

FOR

AW MEASUREMENT

Further evaluation of airflow limitation beyond spirometry

Determining the response to B.D.
Determination of bronchial hyper-reactivity

The commonly used limit for bronchial provocation is a 15 or

20% decrease in FEV1 relative to control baseline FEV1.
The comparable limit for sRtot is 100%, for Rtot 50% increase
and for sGtot 40% decrease from baseline, respectively.

Difference between types of obstructive lung disease

having similar spirometry pattern.
Following the course of the disease and response to
treatment.

121

ASSESSMENT

OF

RAW DATA

122

PARAMETER

OF AIRWAY RESISTANCE

sReff (specific effective airway resistance) which reflects

the larger central airways
sRtot (specific total airway resistance) which reflects the
smaller peripheral airways
The parameter of sR0.5 reflects the behavior of larger ,
more proximal airways with much less sensitivity to
peripheral airways.

123

APPLICATION

OF

RAW

124

DEFINITION OF ABNORMAL LUNG FUNCTION

USING RAW ETC
Threshold to abnormality for Rtot and Reff in
adults: 0.3 kPa/(L/s)
Predicted values for Rtot and Reff in children:
normal if below 150% of predicted
Bronchial hyper-responsiveness
Povocation:
+PD/C 50 in Raw equivalent to -PD/C 20 in FEV1
+PD/C 100 in sRaw equivalent -PD/C 20 in FEV1
-PD/C 40 in sGaw equivalent -PD/C 20 in FEV1
Dilatation:
>25 % response to bronchodilator (children 2-5 yrs

125

126

AIRWAYS OBSTRUCTION

127

RESTRICTIVE LUNG DISEASE

128

EXTRATHORACIC AIRFLOW PROBLEM

129

AIRWAY COLLAPSE

130

BEYOND
131

THE

ROUTINE

OBESITY

AND

LUNG VOLUMES

Small differences in TLC and VC over range of BMIs

132

OBESITY

AND

LUNG VOLUMES

Big differences in FRC and especially ERV over range of BMIs

133

OBESITY

AND

LUNG VOLUMES

134

135

BRONCHODILATOR RESPONSE
Where FEV1 does not significantly improve, patients
often state they feel symptomatically better
Changes have occurred in the degree of hyperinflation,
so work of breathing is reduced.
Raw decreases
FRC decreases
RV decreases
IC increases
Demonstrated for 2-agonists, combination drugs and
anticholinergic drugs
Relate changes in static lung volumes and Raw pre and
136
post treatment to symptomatic improvement (VAS score)
and to 6MWT

137

138

GAS COMPRESSION

139

TRACHEAL STENTING
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 Raw as radius of airway is greater.
FEV1 should also increase and shape of F-V curve
should be more normalized

140

PNEUMOTHORAX

AND

PLEURAL EFFUSION

Possible to make measurements of He dilution and

TGV from body plethysmograph to demonstrate
differences between total volume of the chest and
actual accessible lung volume
TLCpleth TLCHe equates to difference in accessible
gas exchange volume.

141

SUMMARY
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.
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 is recommended in the
assessment of patients undergoing LVRS and may be
used to assess other disorders including spinal cord
injury etc.
Body plethysmography can be used beyond the simple
142
static lung volume measurements

CONTACT & CONSULTANCY

Adrian.Kendrick@UHBristol.nhs.uk

143