Visit us at www.drsarma.

in
Dr. R.V.S.N.Sarma., M.D., M.Sc.,
Consultant Physician & Chest Specialist
E mail: sarma.rvsn@gmail.com
3760 9226 or 2766 0593
93805 21221 or 98940 60593

www.drsarma.in

Pulmonary Function Tests

Ventilatory Function
Spirometry
Clinical Applications

www.drsarma.in

LUNG FUNCTION TESTS

Tests

of Ventilation
Tests of Diffusion
Tests of Perfusion
Tests for V-P Mismatch

www.drsarma.in

LUNG FUNCTION TESTS

Tests

of Ventilation
Tests of Diffusion
Tests of Perfusion
Tests for V-P Mismatch

www.drsarma.in

Function of Ventilation
Air Exit Airways, Bronchomotor tone,
Secretions, Thoracic muscles etc
Air Entry Expansion of lungs
Functioning lung volume, its elastic
nature, Lung compliance
Air Out Problem Obstructive Diseases
Air In problem Restrictive Diseases
Both Air Out and In - Combined

www.drsarma.in

Spirometry
Objectives
To detect Obstructive Airway Diseases
To quantify the severity of obstruction.
To assess response to IBD.
To identify Restrictive Lung Diseases.
To identify flow-volume loop patterns
To understand the clinical relevance.
www.drsarma.in

PEAK FLOW METER

Diagnosis of ASTHMA or COPD can be

confirmed by demonstrating the presence
of airway obstruction using Spirometry.
www.drsarma.in

PEFR - Pros and Cons

Advantages
With

in 1 to 2 minutes,
Inexpensive (meter costs less than Rs.1000)
Simple, useful for frequent follow up use

Disadvantages
Very

much effort dependent

Insensitive to small changes
Small airways cannot be assessed
Large inter & intra subject variation;accurate
www.drsarma.in

SPIROMETRY

www.drsarma.in

SPIROMETRY

www.drsarma.in

SPIROMETRY

www.drsarma.in

SPIROMETRY

www.drsarma.in

Spirometry - Pros and Cons

Advantages
Evaluates

smaller as well as larger airways

Relatively easy to use and maintain
Reversibility can be tested with IBD and steroids
Diagnostic as well as management assessments

Disadvantages
Costs

about 50,000 + computer and printer

Takes time to perform 10 to 15 minutes
Requires training at least one day course
www.drsarma.in

Spirometry Maneuver
In single breath test
A few normal tidal respirations
Then deeeeep inspiration
Momentary breath holding
Very forced and fast expiration
As

hard and as fast as he/she can blow out

Then deep, quick and full inspiration

Repeat at least 3 times take the best

www.drsarma.in

Reproducibility of Spirometry
Adequate explanation to the patient
Demonstrating the steps one by one
Encouraging the patient to give best effort
Taking at least 3 and usually 5 attempts
Selecting the best effort
Cough and severe dyspnoea may interfere
Not like ECG Results depend on effort

www.drsarma.in

Spirometry Results
FVC
FEV1

FEV1/FVC

PEFR
FET

www.drsarma.in

Forced Vital Capacity

Forced Expiratory Volume
in the first second
Ratio of the above two
Peak Expiratory Flow Rate
Forced Expiratory Time

Normal
Flow-Volume

Volume-Time
Test Values

www.drsarma.in

Spirometry Results
FVC
FEV1

FEV1/FVC

PEFR
FET

www.drsarma.in

Forced Vital Capacity

Forced Expiratory Volume
in the first second
Ratio of the above two
Peak Expiratory Flow Rate
Forced Expiratory Time

Spirometry Normal Values

1.

2.
3.

There are no fixed Normal values

Dependent on age, sex, height, weight, ethnicity
Observed value expressed as % of predicted value

FVC
FEV1
FEV1/FVC
PEFR
FET

www.drsarma.in

Normal if > 80% of predicted

Normal if > 80% of predicted
At least 75%
Normal if > 80% of predicted
Less than 4 seconds

FEV1 NORMAL

The Four Square Game

FEV1 < 80% of Pd.

80%

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 NORMAL

The Four Square Game

Normal Lungs
FEV1FCV is N

FEV1 < 80% of Pd.

80%

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 NORMAL

The Four Square Game

FEV1 < 80% of Pd.

80%

Obstructive Disease
FEV1FCV is Low

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

Restrictive Disease
FEV1FCV is High
80%

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

80%

Combined Obs+Res
FEV1FCV is N or L

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

Restrictive Disease
FEV1FCV is High

Normal Lungs
FEV1FCV is N
80%

Combined Obs+Res Obstructive Disease

FEV1FCV is N or L FEV FCV is Low
1

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

Air Entry Problem
Lungs expansion

Normal Air
Entry & Exit

80%

Both Air Entry &

Air Exit Problem

Air Exit Problem

Airways choked

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

Restrictive Disease
FEV1FCV is High

Normal Lungs
FEV1FCV is N
80%

Combined Obs+Res
Obstructive Disease
FEV1FCV is N or L
FEV1FCV is Low

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

Millers Prediction Quadrants

FEV1 < 80% of Pd.

FEV1 NORMAL

100%

Air Entry is reduced

Air In and Out N
Restrictive Disease 90% Normal Lungs
FEV1FCV is High
FEV1FCV is N

60%

70%

80%

90%

100%

Both Air In & Out

Air Exit is chocked
Combined Obs+Res
Obstructive Disease
70%
FEV1FCV is N or L
FEV1FCV is Low
60%
FVC < 80% Pred.

www.drsarma.in

FVC NORMAL

Algorithm for Diagnosis

FVC
FVC > 80%

FVC < 80%

FEV1 > 80%

FEV1 < 80%

FEV1 > 80%

FEV1 < 80%

Normal PFT

Obstructive

Restrictive

Combined

Extra-pulmonary

Pulmonary

IBD

Reversible
www.drsarma.in

Irreversible

Normal Airways and Lungs

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

FVC
FEV1
FEV1FCV

> 80%
> 80%
> 75%

PEFR
FET

> 80%
<4 sec

Air Entry
Air Exit

Normal
Normal

Normal Airways - PFT

www.drsarma.in

Normal PFT and CXR

www.drsarma.in

Obstructive Airways Disease

Bronchial Asthma Reversible Airway obs.
Chronic bronchitis Irreversible with IBD
Emphysema Irreversible with IBD
Bronchiectasis Airway rigidity
Cystic Fibrosis
Allergic bronchopulmonary Aspergillosis
Bronchiolitis

www.drsarma.in

Obstructive Airways Disease

FVC
FEV1
FEV1FCV

> 80%
< 80%
< 75%

PEFR
FET

< 80%
>4 sec

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Air Entry
Air Exit

Normal
Problem

Obstructive Airways Disease - PFT

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Obstructive V/s Normal

www.drsarma.in

Obstructive Airways Mild

Bronchial Asthma
www.drsarma.in

Reversible Obstruction (IBD)

Bronchial Asthma
www.drsarma.in

Bronchiectasis (Obstructive)

BRONCHOGRAM - BIL
www.drsarma.in

UNILATERAL

Obstructive Airways Severe

Emphysema
www.drsarma.in

Obstructive Airways Severe -IBD

Emphysema
www.drsarma.in

Obstructive Lung Diseases

ABPA
www.drsarma.in

CYSTIC FIBROSIS

Upper Airway Obstruction

Truncation of flow loop

Expiratory Intra Thoracic
Inspiratory Extra Thoracic
Both Fixed Obstruction
Tumour
Tracheal stenosis
Tracheal FB
Vocal Chord Dysfunction

www.drsarma.in

Restrictive Lung Diseases

Sarcoidosis
Tuberculosis (Fibrocaseous)
Interstitial Lung Disease - ILD
Idiopathic pulmonary fibrosis - IPF
Pneumoconiosis
Drug- or radiation-induced lung disease
Pneumonectomy

www.drsarma.in

Extrinsic Restrictive Diseases

Kyphosis, Scoliosis
Ankylosing Spondylitis
Massive Pleural effusion
Pregnancy, Obesity, Ascites
Rib fractures
Neuromuscular disorders

www.drsarma.in

Restrictive Lung Disease

FVC
FEV1
FEV1FCV

< 80%
> 80%
> 75%

PEFR
FET

> 80%
<4 sec

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Air Entry
Air Exit

Problem
Normal

Restrictive Lung Disease - PFT

ILD or IPF

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Restrictive V/s Normal

ILD or IPF

www.drsarma.in

Restrictive Lung Disease - ILD

ILD or IPF

www.drsarma.in

Restrictive Lung Disease - ILD

HEPATIOD APPEARANCE
www.drsarma.in

Restrictive Lung Disease - ILD

RETICULAR PERIPHERIES
www.drsarma.in

Restrictive Lung Disease - ILD

HRCT Chest
www.drsarma.in

X-RAY CHEST - ILD

Restrictive Lung Diseases

SARCOIDOSIS
www.drsarma.in

RETICULO-NODULAR

Combined Obstructive + Restrictive

FVC
FEV1
FEV1FCV

< 80%
< 80%
< 75%

PEFR
FET

< 80%
>4 sec

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Air Entry
Air Exit

Problem
Problem

Combined Obstructive + Restrictive

FEV1 is LOW

FVC is Normal
FEV1 FVC
is < 75%

www.drsarma.in

Combined Obstructive + Restrictive

KOCHS + EMPHYSEMA
www.drsarma.in

Other Patterns
FIXED
OBSTRUCTION

www.drsarma.in

Other Patterns
COUGH

EXTRA THORACIC

www.drsarma.in

Case 1
Test

Pred.

Meas. %

FVC

5.5 L

4.5 L

82%

FEV1

4.9 L

3.0 L

61%

Ratio

89%

66%

Man, aged 28, 172cm, 71kg

Non smoker, Cough 3 M

www.drsarma.in

Case 1
Test

Pred.

Meas. %

FVC

5.5 L

4.5 L

82%

FEV1

4.9 L

3.0 L

61%

Ratio

89%

66%

IBD Good
Response

Man, aged 28, 172cm, 71kg

Non smoker, Cough 3 M

Dx : Bron Asthma - Rev
www.drsarma.in

Case 2
Test

Pred.

Meas. %

FVC

3.9 L

2.6 L

66%

FEV1

3.1 L

2.4 L

78%

Ratio

79%

92%

Woman, 48 y, 155cm, 47 kg

Non smoker, Dysp., CP

www.drsarma.in

Case 2
Test

Pred.

Meas. %

FVC

3.9 L

2.6 L

66%

FEV1

3.1 L

2.4 L

78%

Ratio

79%

92%

Woman, 48 y, 155cm, 47 kg

Non smoker, Dysp., CP

Diagnosis : # Ribs 5,6,7,8
www.drsarma.in

Case 3
Test

Pred.

Meas. %

FVC

6.0 L

5.0 L

83%

FEV1

4.8 L

4.1 L

85%

Ratio

80%

82%

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

www.drsarma.in

Case 3
Test

Pred.

Meas. %

FVC

6.0 L

5.0 L

83%

FEV1

4.8 L

4.1 L

85%

Ratio

80%

82%

Man 35, 175cm, 75kg, MC

Non smoker, Clinical N

Diagnosis : Normal PFT
www.drsarma.in

Case 4
Test

Pred.

Meas. %

FVC

1.9 L

0.7 L

36%

FEV1

1.6 L

0.4 L

25%

Ratio

84%

57%

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.

www.drsarma.in

Case 4
Test

Pred.

Meas. %

FVC

1.9 L

0.7 L

36%

FEV1

1.6 L

0.4 L

25%

Ratio

84%

57%

Child, 8 y, 128 cm, 19 kg

Stridor, Dysp G3, BS Decr.

FB in the UAW
www.drsarma.in

Case 5
Test

Pred.

Meas. %

FVC

3.5 L

1.8 L

51%

FEV1

2.8 L

1.2 L

43%

Ratio

80%

66%

Woman, 29 y, 160cm, 41 kg

Had ATT, Dysp G3, Wheeze

www.drsarma.in

Case 5
Test

Pred.

Meas. %

FVC

3.5 L

1.8 L

51%

FEV1

2.8 L

1.2 L

43%

Ratio

80%

66%

Woman, 29 y, 160cm, 41 kg

Had ATT, Dysp G3, Wheeze

Diagnosis : TB + ABPA
www.drsarma.in

Case 6
Test

Pred.

Meas. %

FVC

4.5 L

3.7 L

82%

FEV1

3.6 L

1.8 L

50%

Ratio

80%

49%

Man, aged 58, 165cm, 51kg

Smoker 16yr, Severe Dysp.

www.drsarma.in

Case 6
Test

Pred.

Meas. %

FVC

4.5 L

3.7 L

82%

FEV1

3.6 L

1.8 L

50%

Ratio

80%

49%

IBD NO
Response

Man, aged 68, 165cm, 51kg

Smoker 16yr, Severe Dysp.

DX :COPD- Irreversible
www.drsarma.in

FEV1 < 80% of Pd.

FEV1 NORMAL

The Four Square Game

Restrictive Disease
FEV1FCV is High

Normal Lungs
FEV1FCV is N
80%

Combined Obs+Res
Obstructive Disease
FEV1FCV is N or L
FEV1FCV is Low

80%
FVC < 80% Pred.
www.drsarma.in

FVC NORMAL

Millers Prediction Quadrants

FEV1 < 80% of Pd.

FEV1 NORMAL

100%

Air Entry is reduced

Air In and Out N
Restrictive Disease 90% Normal Lungs
FEV1FCV is High
FEV1FCV is N

60%

70%

80%

90%

100%

Both Air In & Out

Air Exit is chocked
Combined Obs+Res
Obstructive Disease
70%
FEV1FCV is N or L
FEV1FCV is Low
60%
FVC < 80% Pred.

www.drsarma.in

FVC NORMAL

Take Home Points

All that wheezes is not Asthma only

All Dyspnoea does not wheeze

Do not over simplify dyspnoea to Deriphyllin

Etiology of Dyspnoea needs elucidation

Spirometry tests but Ventilation function only

Need to test diffusion, Perfusion functions

Cardiac, Hematologic and other causes

www.drsarma.in

www.drsarma.in