Body

Plethysmography
 Body plethysmography measures
• Intrathoracic gas volume (TGV)
• FRC
• Lung volume sub divisions

• Airway resistance and conductance

 Limitations of other methods
• Helium dilution technique

• Nitrogen washout technique

• FRC may be underestimated in obstructive

lung disease due to poor gas mixing
(trapped areas
 Measurement of
airway resistance and
conductance
 Let’s understand AIRWAY RESISTANCE

The relationship between pressure and flow

tells us about airway resistance

Resistance arises from the pressure losses* in

the gas flowing between the alveoli and the
atmosphere

* Type of flow (laminar/ turbulent) and airway

diameter
• Maximum resistance in the airway is in the
larynx, trachea and medium sized bronchi
upto the 7th generation of branching
 Resistance of the respiratory system

• Lung resistance= lung tissue R + airway R

(Raw)
Raw= resistance in the airway between
mouth and alveoli

• Total respiratory resistance (Rtotal)

R total =chest wall R +lung tissue R +Raw

(measured by impulse oscillometry)

 Methods to measure airway resistance

Oesophageal balloon method

Body plethysmography

Impulse oscillometry
 Why measure Raw?
Further evaluation of airflow limitation beyond spirometry

To determine BDR

To determine bronchial hyperreactivity

Bronchoprovocation

To differentiate between types of obstructive lung disease

having similar spirometeric configuration

To assess progress of a disease

To assess response to treatment

 Q = air flow
• Q = ΔP / R

• airflow is directly proportionate to pressure

difference atmospheric pressure (at mouth
and nose Pmo) and alveolar pressure Palv

• airflow is inversely proportional to airway

resistance
Airway resistance
Raw = atmospheric pressure – alveolar pressure = P
flow V

Airway conductance – the flow generated per unit drop

in pressure between alveoli and mouth
Gaw = 1/Raw

Specific conductance – the rate of flow with respect to

change in thoracic gas volume
SGaw = 1/Raw/TGV (thoracic gas volume)
 Contraindications for use of the body
box:
1-Mental confusion, muscular incoordination, body cast or any
other condition that prevent the patient from entering the
box

2-Claustrophobia

3-Presence of devices or other condition such as continuous

I.V infusion
Or any condition that interfere with pressure changes (e.g
chest tube, transtracheal O2 catheter, or ruptured ear
drum).

4-Continuous O2 therapy that can not be removed.

 Principle

• The patient sits inside an airtight box

• Inhales or exhales to a particular volume (usually FRC)
• A shutter drops across their breathing valve
• The subject makes respiratory efforts against the closed
shutter causing their chest volume to expand and
decompressing the air in their lungs
• The increase in their chest volume slightly reduces the box
volume and thus increases the pressure in the box
• This method of measuring FRC actually measures all the
conducting pathways including abdominal gas; the actual
measurement made is the TGV (Thoracic Gas Volume)
To compute the volume of air in the lungs

• First compute the change in volume of the chest

• Using Boyle's Law (P1 V1 = P2 V2 at constant temperature)

• Initial pressure in the box x initial volume of the box (both

known) = pressure x volume of the box at the end of a
chest expansion (only pressure is known)

• The difference between this volume and the initial volume

of the box is the change in volume of the box, which is the
same as the change in the volume of the chest
• Boyle's Law states that:
– V1 P1 T1 = V2 P2 T2

• For the plethysmograph, the temperature is kept constant so:

– P1 V1 = P2 V2
• Where:
P1 and V1 are initial pressure and volume.
P2 and V2 are final pressure and volume.
Note: Both measurements are made at a constant temperature.
 Technique
• The subject is enclosed in the plethysmograph
• Time allowed for equilibration of temperature and
pressure
• The patient should sit upright
• He has to hold his head in neutral position or in
slight extension, avoiding flexion or rotation
• He is asked to breathe normally through the
pneumotachograph
• Care has to be taken, that the lips are firmly closed
around the mouthpiece and the nose is clipped
 Technique contd…
• The patient is asked to ‘pant’ at a frequency
of 1 breath per second (hold cheeks)
• During inspiration – alveolar pressure
decreases and alveolar volume (V)
increases
• During expiration – vice versa
• The change in volume causes a proportional
change in the plethysmograph pressure
(Pbox)
Calculation of airway resistance
 Airway Resistance
Flow
Breathe IN

+0.5 L/s

 ΔPbox

-0.5 L/s

Breathe Out
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 a
subject with upper airway obstruction. Mouth flow (V') is plotted on the vertical axis, with
inspiration positive and expiration negative
 Parameters of airway resistance
sReff ( specific effective airway resistance)
Reflects larger; central airways more prominently
than sR tot

sRtot(specific total airway resistance)

Reflects smaller; peripheral airways

sR0.5
Reflects the behavior of larger, more proximal
airways
• Predicted values for Rtot and Reff in children:
normal if below 150% of predicted

• Standard for RV:

abnormal, if above 120-140 % of predicted

• Standard for TLC:

abnormal, if above 120-140 % of predicted
 RV/TLC %.

Normal value of RV/TLC % in normal young

adult 20 -35 %

Increased RV/TLC % indicates air trapping

Hyperinflation of the lung is demonstrated

when there is increased RV/ TLC % and TLC
Calculation of intrathoracic gas
volume/ FRC
• The shutter is closed at end expiration

• Patient continues to breathe normally

• When there is no airflow; the Pmo = Palv

• Plot of Pbox versus Palv

• Slope gives the iTGV

Patterns of lung volume changes
 Severity of lung volume disorders

TLC ( N.80 -120 %of predicted)

Degree Restrictive Obstructive

Mild 70 -80 % 120 -130 %

Moderate 60 -70 % 130 -150 %

Severe < 60 % > 150 %

VOLUME Restrictive Air Hyperinflation
pattern trapping

RV/TLC% Normal Increased Increased

TLC Decreased Normal Increased

RV Decreased Increased Increased

FRC Decreased Increased Increased

VC Decreased Decreased Normal

Two obstructive pattern are possible one
where there is increase RV results in
proportional reduction in VC where TLC
remain normal ( air trapping )

The 2nd , RV increase with little or no

changes in VC this cause an increase in
TLC in direct proportion with RV
(hyperinflation)

An abnormally increase in RV/TLC% will

demonstrated in both pattern
Some disorders