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Lung Diseases
Restrictive:
Any process that interferes with the bellows
action of the lungs or chest wall.
Reduced lung volumes.
Differential Diagnosis:
COPD and Asthma
COPD Asthma
Onset In mid-life Onset early in life (often
Symptoms slowly childhood)
progressive Symptoms vary from day to day
Long smoking history Symptoms at night/early
Dyspnea during exercise morning
Largely Irreversible Allergy, rhinitis, and/or eczema
airflow limitation also present
Family history of asthma
Largely reversible airflow
limitation
Inflammatory Cascade in
COPD & Asthma
Measures of Assessment and
Monitoring of Asthma
Asthma diagnosis criteria:
Repeated variability in well-performed
spirometic values (increase in FEV1 or FVC).
Positive bronchodilator (BD) responses
(increase in FEV1 or FVC ⩾12% and 200 mL
from baseline).
Positive methacholine challenge (20% fall in
FEV1 at a dose ⩽8 μg/mL).
Objective lung function
measurements in Asthma
Spirometry:
▫ Forced Expiratory Maneuvers.
Exhaled Nitric Oxide.
Peak Flows.
GOLD 2013: Diagnosis of COPD
Key Indicators to Consider COPD Diagnosis:
• SYMPTOMS
• Dyspnea-progressive (worsens over time and with exercise)
1 • Chronic cough
• Sputum
http://www.aduk.org.uk/gfx/lungs.jpg
The Airways
Conducting zone: no
gas exchange occurs
Anatomic dead
space
Transitional zone:
alveoli appear, but are
not great in number
Respiratory zone:
contain the alveolar
sacs
Weibel ER: Morphometry of the Human
Lung. Berlin and New York: Springer-
Verlag, 1963
The Alveoli
Approximately 300
million alveoli
1/3 mm diameter
Total surface area if
they were complete
spheres 80 sq.
meters (size of a
tennis court)
FVC
Terminology
Forced expiratory volume
in 1 second: (FEV1)
Volume of air forcefully
expired from full inflation
(TLC) in the first second
Measured in liters (L)
Normal people can exhale
more than 75-80% of their
FVC in the first second;
thus the FEV1/FVC can
be utilized to characterize
lung disease
FEV1
Interpretation of % predicted:
>75% Normal
Mild 70-75%
Mod 50-69 %
Severe 35-49%
Very severe < 35%
FEV1 FVC
Terminology
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
TLC
TLC < 80% of predicted value = restriction.
TLC > 120% of predicted value =
hyperinflation.
Lung Volumes
Spirometry
Spirometry should be performed after the
administration of an adequate dose of a short
acting inhaled bronchodilator (e.g. 400 ᶙg
salbutamol) to minimize variability.
A post-bronchodilator FEV 1/FVC <0.70
confirms the presence of airflow limitation that
is not fully reversible.
Where possible, values should be compared to
age-related normal values to avoid over-
diagnosis of COPD In the elderly.
Why Do We Need Spirometry
in COPD?
Spirometry is useful for:
Screen individuals at risk for pulmonary
disease.
Confirmation of COPD diagnosis.
Assessing severity of pulmonary dysfunction.
Guiding selection of treatment.
Assessing the effects of therapeutic
interventions.
Who Should Be Screened for
COPD?
Consider COPD, and perform spirometry, if any of these
indicators are present in an individual over age 40.
▫ Dyspnea that is progressive, usually worse with
exercise, and persistent.
▫ Chronic cough (may be intermittent and
unproductive).
▫ Chronic sputum.
▫ History of tobacco smoke exposure.
▫ Exposure to occupational dusts and chemicals.
▫ Risk factors.
▫ Exposure to smoke from home cooking and
heating fuels.
Spirometry Origin
Measurements of:
Forced Vital Capacity (FVC).
Forced Expiratory Volume in one second
(FEV1).
Forced Expiratory Volume in six seconds
(FEV6).
Forced Expiratory Flow over various Intervals
(FEFx).
Peak Expiratory Flow (PEF).
Definitions and Terms
FEV1 - forced expiratory volume 1 - the volume of
air that is forcefully exhaled in one second.
■ Assess severity
■ Disability
1-First Step, Check quality of the
test
1- Start:
*Good start: Extrapolated volume (EV) <
5% of FVC or 0.15 L
*Poor start: Extrapolated volume (EV)
≥5% of FVC or ≥ 0.15 L
2- Termination:
*No early termination :Tex ≥ 6 s
*Early termination : Tex < 6 s
2- Look at …………FEV1/FVC
6- Look at TLC
3- Look at FVC
4-Look at FEF25/75
> 50% Normal < 50% SAWD
Patterns of Abnormality
Volume
8 concave FV curve
Flow in L/s
0
0 1 2 3 4 5 6
Litres
Restrictive
12 F 19 yrs 1.64m
10 FVC 2.41 L -3.42 SR
FEV 2.41 L -2.62 SR
8 FEV% 100 +2.23 SR
PEF 5.55L/s -2.00 SR
6 F/P 7.2 RT 116 ms
Flow in L/s
2
0
0 1 2 3 4 5 6
-2 Litres
-4
-6
-8
10
COPD
8
pressure dependent airways collapse
6
4
Flow in L/s
0
0 1 2 3 4 5
Litres
-2
-4
-6
Poorly co-ordinated start
12
EV = large
Rise Time = 496 ms
10
Irregular shape
8
Poorly repeatable
6
2
Flow in L/s
0
0 1 2 3 4 5 6
-2 Litres
-4
-6
-8
-10
Upper Airway Obstruction
0
0 1 2 3 4 5 6
-2 Volume in Litres
-4
FEV1 in mls > 8
Inspiratory PEF in L/min
-6
Upper Airway Obstruction
12
Male aged 62 Height 1.68m
10 R e co rd e d P re d icte d R an ge SR
FEV 1 2.23 2.94 2.1 to 3.8 -1.4
8
FV C 3.40 3.71 2.7 to 4.7 -0.5
FEV 1 % FV C 66 76 64 to 88 -1.5
6
P EF 2.85 7.81 5.8 to 9.8 -4.1
Flow in L/s
FEV 1 /P EF 13.1
4
0
0 1 2 3 4 5 6
-2 Volume in Litres
-4
-6
Variable UAO
Inspiration Expiration
-ve +ve
-ve +ve
12
Age 65 Female
FVC 2.97 L 1.3 SR
10
FEV1 2.26 L 0.6 SR
8 FEV1% 76% -0.1 SR
PEF 3.4 L·s-1 -2.5 SR
Flo w in L /s
0
0 1 2 3 4 5 6
-2 L ite rs
-4
-6
-8
Upper Airway Obstruction
• Variable extrathoracic obstructions
1. vocal cord paralysis,
2. thyromegaly,
3. tracheomalacia, or
4. Neoplasm
• Large airways variable intrathoracic obstructions
1. tracheomalacia or
2. neoplasm
• Fixed obstruction
1. tracheal stenosis,
2. foreign body, or
3. neoplasm.
Obstruction, Restriction, Mixed
Variable Extrathoracic Upper
Airway Obstruction
Fixed Upper Airway Obstruction
True Restrictive Disorders
Intraparenchymal
Chest Wall
Normally: IC/ERV=2-3/1
Pseudorestrictive: IC/ERV=6/1
Pseudorestrictive Disorders
Obesity:
*Early airway closure (low ERV & high RV)
*FRC is more reduced than TLC&VC
*Low FEF50% FEF75%, FEF25-75%,
,
Pseudorestrictive Disorders
Neuromuscular Disease:
*FRC normal
*IC&ERV decreased
*Decreased TLC
*Increased RV
*A-aO2 gradient normal
*MIP&MEP decreased
Pseudorestrictive Disorders
Asthma:
*FRC &TLC increased
*Improvement of FEV1&FVC with bronchodilators
*Positive bronchoprovacation test
*Increased diffusing capacity and DLco/VA
Pseudopseudorestrictive
*Sarcoidosis
*Rhematoid
*Advanced IPF
*Bronchiectasis
*BOOP in smokers
Obstructive Pattern
■ Decreased FEV1
■ Decreased FVC
■ Decreased FEV1/FVC
- <70% predicted
Asthma
COPD
- chronic bronchitis
- emphysema
Bronchiectasis
Bronchiolitis
Upper airway obstruction
Restrictive Pattern
Decreased FEV1
Decreased FVC
Pleural
Parenchymal
Chest wall
Neuromuscular
Spirometry Patterns
Bronchodilator Response
“Spirogram”
Fixed obstruction
Upper Airway Obstruction
Lung Volumes
Measurement:
- helium
- nitrogen washout
- body plethsmography
Indications:
- Diagnose restrictive component
- Differentiate chronic bronchitis from
emphysema
Lung Volumes – Patterns
Obstructive
- TLC > 120% predicted
- RV > 120% predicted
Restrictive
- TLC < 80% predicted
- RV < 80% predicted
Diffusing Capacity
Depends on:
- alveolar—capillary membrane
- hemoglobin concentration
- cardiac output
Diffusing Capacity
Common agents:
- Methacholine, Histamine, others
Asthma