Pulmonary

Function
Testing
Camilla Hollen, MMS, PA-C
PA 530

Objectives
B.1- Describe the indications, contraindications, and
potential complications associated with pulmonary
function testing.
B.2- Describe a provocation study and its impact on
the patient during a pulmonary function study.
B.3- Illustrate lung volumes and capacities
associated with normal breathing.
B.4- Distinguish among restrictive, obstructive, and
mixed pulmonary disease patterns when given
results of pulmonary function testing.

Objectives
B.5- Describe the indications and situations for
using a peak flow meter.
B.6- Assess the technique for using a peak flow
meter.
B.7- Evaluate the results from a peak flow
measurement and correlate them with mild,
moderate, and severe levels of asthma.

Pulmonary Function Testing

Indications
Pulmonary disease
presence
etiology
assessment of severity

Effectiveness of therapy/Monitoring of disease

Reversibility of obstruction
Epidemiological surveillance
occupational, environmental, drug exposure

Preoperative (controversial)
Disability- objective assessment

Pulmonary Function Testing

Contraindications
Absolute: within 1 month of MI or unstable CVD
Relative:

Hemoptysis of unknown origin

Pneumothorax
Thoracic, abdominal, or cerebral aneurysms
Recent eye, thoracic, or abdominal surgery

Complications
Bronchospasm, paroxysmal coughing, O2 desat,
chest pain, syncope, dizziness, pneumothroax,
increased ICP, spread of infection

Suboptimal Testing
Age <5: Too young to follow directions
Chest or abdominal pain
Oral/facial pain exacerbated by mouthpiece
Stress incontinence
Dementia

Pathophysiology
Two major categories of pulmonary disease:
-Obstructive disease
-Restrictive disease
Can have mixed disease as some pulmonary
diseases have both obstructive and
restrictive patterns.

Obstructive
Obstructive disorders- ex: emphysema or
asthma
airflow limitation
increased lung volumes with air trapping
normal or increased compliance (based on
pressure volume profile)

Restrictive
Restrictive disorders- ex: pulmonary fibrosis
reduced lung volumes
increase in overall stiffness of the lungs (with
reduced compliance)

Common Disorders
Obstructive

Restrictive

Asthma, Asthmatic
bronchitis, Chronic
obstructive bronchitis,
Chronic obstructive
pulmonary disease
(includes asthmatic
bronchitis,chronic
bronchitis, emphysema,
and the overlap between
them), Cystic fibrosis,
Emphysema

Beryllium disease,
Congestive heart failure,
Idiopathic pulmonary
fibrosis, Infectious
inflammation (e.g.,
histoplasmosis,
mycobacterium infection),
Interstitial pneumonitis,
Neuromuscular diseases,
Sarcoidosis, Thoracic
deformities

3 components to PFT
Measuring lung volumes and
capacities
Measuring airway mechanics
Measuring diffusion capacity of the
lung

Volumes / Capacities

In a nutshell.
Vital Capacity = IRV + VT + ERV
Inspiratory Capacity (IC) = VT + IRV
Functional Residual Capacity (FRC) = ERV + RV
Total Lung Capacity (TLC) = IC + FRC

Obstructive Lung Disorders

Restrictive Lung Disorders

Pulmonary measurements
Forced Vital Capacity (FVC)
Forced Expiratory Volume Timed (FEVT)
FEV1/FVC Ratio
Forced Expiratory Flow 25%-75%
Peak Expiratory Flow Rate (PEFR)
Flow-Volume Loop

Forced Vital Capacity (FVC)

Maximum volume of gas that is exhaled as
forcefully and rapidly as possible after a
maximal inspiration
Most common
3 attempts

Forced Vital Capacity (FVC)

Forced Expiratory Volume Timed

(FEVT)
Maximum volume of gas exhaled
in a specific time, usually 1.0 sec.
(FEV1)
Obtained from FVC maneuver
Decreases with age

Forced Expiratory Volume Timed

(FEVT)

FEV1/FVC Ratio
Compares the amount of air exhaled in 1.0
sec to total amount exhaled during FVC
maneuver
Expressed as a percentage (FEV1%)
Normal ~ 75-85% (65% acceptable in older
patients)

Normal FEVT/FVC
FEV0.5 60%
FEV1 83%
FEV2 94%
FEV3 97%

Together, FVC, FEV1 & FEV1%...

Are most common
Determine severity
Distinguish type

Forced Expiratory Flow 25%-75%

Average flow rate during the middle 50% of FVC
Condition of medium to small-sized airways
No value in distinguishing lung disease (?)
Decreases with age
Normals
Male age 20-30:
Female age 20-30:

4.5 L/sec (270 L/min)

3.5 L/sec (210 L/min)

Forced Expiratory Flow

FVC

Reversibility
Bronchodilator administered then
spirometry repeated.
Indicates effective therapy.
Defined as >15% improvement in FEV1
AND at least a 200 mL increase in FEV1
% change = [(post pre) / pre ] x 100

Flow-Volume Loop
FVC followed by FIV
2 curves produce a loop
Compares flow rates and volume

Normal Flow-Volume Loop

Fixed Large Airway Obstruction

Flow-Volume Loop, Obstructive

Pattern

Flow-Volume Loop, Restrictive

Pattern

PFT Results

Bronchoprovocation
Indication- unclear diagnosis, esp if baseline
spirometry is normal.
Assess if airways are reactive.
5 successive challenges with chemical
(methacholine or mannitol) at increasing
concentrations.
>20% reduction in FEV1 = positive test for
reactivity.

Bronchoprovocation
Positive test is very sensitive for bronchial
asthma.
Can also be a false positive in COPD,
parenchymal respiratory disorders,
congestive heart failure, recent upper
respiratory tract infection, and allergic
rhinitis.

Peak Flow Meters

Purpose
Use patients personal best to develop an
asthma action plan

Inexpensive, portable device

Peak Expiratory Flow

Measured in Liters/Minute.
Measures forceful exhalation for monitoring
asthma primarily.
Can typically be used in individuals age 5 and up.
Utilized to identify triggers or early exacerbations.
Most often used in those on daily medicines.
Should be performed same time daily.

What does the number

mean?
http://www.asthma.partners.org/newfiles/
Appendix2.html
Highly individual. Depends on weight, height,
age, sex.
Most useful compared to patients own
norms.

How To Use a Peak Flow

Meter
Move the marker to the bottom of the
numbered scale.
Patient stands up straight, takes a deep
breath to fill lungs completely, and places
mouthpiece in mouth with lips sealed around
it.

How To Use a Peak Flow

Meter
Patient must blow out as hard and fast as possible.
Record the number obtained with appropriate effort.
-Do not record if patient coughs or air flow obstructed.
Move the marker back to the bottom and repeat these
steps until 3 good readings are obtained.
-The highest of the three numbers is the peak flow.

Asthma Action Plan

Green Zone: Doing Well
80-100% of personal best peak flow
Continue with current medication regimen

Yellow Zone: Asthma is Getting Worse

50-80% of personal best peak flow
Add quick-relief meds and step-up
medications if needed

controller

Red Zone: Medical Alert

<50% of personal best peak flow
Add quick-relief meds
Follow specific instructions from provider or be seen

Asthma Control Test

Validated questionnaire to assess asthma control
Patient recalls symptoms over previous 4 weeks
Scoring:
>20 reflects good asthma control
<19 reflects poor asthma control

Exhaled Nitric Oxide

eNO is a byproduct of inflammation.
Easy, in-office assessment
Tool for monitoring treatment response
Falsely decreased in smokers.

Questions?