Pulmonary function tests

INTRODUCTION Pulmonary function testing (PFT) in children plays an

important role in the evaluation of the child with known or suspected
respiratory disease.
Uses
It allows for assessment of normal lung and airway growth; the natural
history of diseases (eg, bronchopulmonary dysplasia, cystic fibrosis [CF]);
the site and type of obstruction (central versus peripheral, intrathoracic
versus extrathoracic, fixed versus variable); the impact of therapies (eg,
bronchodilators, glucocorticoids, diuretics, mucolytics); and the degree of
impairment. PFT can also be used to assess the impact of environmental
factors (eg, tobacco smoke, toxic gases) and the degree of airway
reactivity. In addition, PFT can aid in preoperative assessment of the child
with chronic lung disease or neuromuscular weakness. Furthermore,
measures of lung function (eg, forced expiratory volume in one second
[FEV1]) have prognostic value with regards to mortality in some diseases
like CF.
PFT is recommended by the National Asthma Education and Prevention
Program (NAEPP) and the Global Initiative for Asthma (GINA) in the
assessment and long-term monitoring of patients with asthma [1]. There
is a growing need for PFT as the incidence of childhood asthma continues
to rise. The development of compact and affordable instruments also
enables pediatric lung function testing in the primary care setting.
A basic approach to PFT for the primary care provider is presented here.
The goal is to encourage pediatricians to obtain PFT to diagnose and
monitor the pathophysiologic aspects of their patients' respiratory
conditions, thereby improving management.
Conventional tests that are frequently performed in the evaluation of
pediatric respiratory conditions include measurements that identify:
Airway obstruction
Restrictive lung, chest wall, and respiratory muscle defects
Diffusion defects (those that impair diffusion of gas through the alveolarcapillary membrane)
Respiratory muscle weakness

Measurements of flow and volume are most useful in the office setting.
Spirometry, which provides both these measures, requires neither
sophisticated technology nor expensive equipment, is easily interpreted,
and is reliable when performed correctly. A brief discussion of the
technique, clinical applications for and limitations of more sophisticated
measurements of lung volume, diffusion capacity, and respiratory muscle
function also is provided so that referrals for such testing can be made
appropriately.
Readers interested in a more comprehensive review of PFT in children are
referred elsewhere [2].
Interpretation of arterial blood gas analyses and exhaled nitric oxide,
exercise testing, assessment of bronchial hyperresponsiveness, sleep
studies, measurements of control of breathing, and PFT in adults are
discussed separately. (See "Oxygenation and mechanisms of
hypoxemia" and "Exhaled nitric oxide analysis and
applications" and "Overview of aerobic exercise testing in children and
adolescents" and "Bronchoprovocation testing" and "Evaluation of
suspected obstructive sleep apnea in children", section on
'Polysomnography' and"Control of ventilation" and "Overview of
pulmonary function testing in adults".)
SPIROMETRY
Overview Spirometry is the measurement of breathing over time. It
includes measures of flow and volume generated by a forced and
complete exhalation to residual volume (RV) after a full inspiration. The
volume-time curve graphic presentation (figure 1) has been largely
replaced in clinical practice by the flow-volume curve (figure 2 and figure
3), which provides a more immediate and intuitive perception of
obstructive and restrictive disorders. However, the two graphic depictions
are complementary and optimally should be analyzed together.
Spirometry also includes the measurement of flow and volume with
inspiration; however, inspiratory parameters are less commonly measured
and are not discussed here. (See "Flow-volume loops".)
Production of a reliable, sustained expiration requires coaching from the
clinician and both coordination and focus on the part of the subject. Thus,
spirometry is usually not obtainable predictably from children younger
than six years.
Spirometry is most useful for evaluation of common pediatric obstructive
lung diseases, such as asthma, cystic fibrosis (CF), and the sequelae of
bronchopulmonary dysplasia.

The following discussion of spirometry focuses on the measured

parameters, interpretation, and clinical applications most relevant to the
primary care provider. Methodology and interpretation of spirometry in
children are discussed in greater detail in guidelines published by the
American Thoracic Society (ATS) [3], accessed through the ATS website.
Measured parameters The important parameters derived from
spirometry include indices of flow:
Forced expiratory volume in one second (FEV1)
Flow between 25 and 75 percent of the vital capacity (FEF25-75%), also
known as the maximal midexpiratory flow rate (MMEFR)
Peak expiratory flow rate (PEFR)
These parameters also include indices of volume:
Forced vital capacity (FVC)
Slow vital capacity (SVC) performed with a submaximal expiratory effort
The air left in the lungs at the end of expiration (RV) cannot be measured
by spirometry. Thus, any lung capacity measurement that includes RV as a
component cannot be derived by spirometry.
The measured values for these parameters are compared with normative
data and are reported as the percent of predicted value for subjects of
similar age, height, gender, and race [4]. Children with chronic conditions
can also be monitored by comparing their measured values with those
obtained at previous visits [1].
Interpretation The interpretation of spirometry depends upon which
parameters are affected (table 1). As a general rule, obstructive disorders
affect indices of flow and restrictive disorders affect indices of volume.
FEV1, FEF25-75%, and PEFR are decreased in obstructive disorders. FEF2575% represents flow in smaller conducting airways. It is less effort
dependent than the other parameters, and it is a particularly useful
measurement of milder intrathoracic airway obstruction. It can be reduced
by 25 percent or more when the patient is symptom free and/or has a
normal lung examination, and in the presence of normal FEV1 and PEFR
[5]. Such reduction in FEF25-75% can be visually noted as scooping of the
flow-volume curve (figure 3).
FVC typically is decreased in restrictive disorders, but may also be low due
to gas trapping and hyperinflation in obstructive defects. In addition to
affecting FVC, restrictive disorders can also lower parameters of flow.

FEV1is typically reduced, since the volume at the initiation of the

expiratory maneuver is lower. Thus, a restrictive disorder should be
considered when flow indices are lowered to a similar extent as the
reduced FVC. A normal FEV1/FVC ratio of >85 percent suggests that the
observed decrease in flow is due to volume reduction rather than
obstructed flow. In this setting, additional measurements of lung volume
using methods unavailable in the primary care setting should be
undertaken to confirm the restrictive respiratory disorder. (See 'Lung
volume measurement' below.)
Many children have both restrictive and obstructive abnormalities in lung
functions. These patterns can be difficult to interpret. A reduced FVC out
of proportion to the reduced FVC/FEV1 may indicate that an additional
restrictive element exists. When in doubt, referral to a pulmonary function
laboratory will be helpful.
Faulty technique will yield unreliable results, and many children are unable
to perform the maneuvers adequately. The two major parameters to follow
are reproducibility of the flow-volume curve and the duration of the
expiratory maneuver. The latter is variable at young ages, but should
always exceed one second and plateau for reliable interpretation.
Flow-volume curve The flow-volume curve is a graphic representation
of individual forced expiratory maneuvers. It is included in most
spirometry reports; only the expiratory limb is typically displayed (figure
2). Obstructive defects are portrayed by scooping of the descending limb
of the curve (figure 3), a change that can be easily detected by the
experienced observer. The graphic display of the flow-volume curve also
provides the best measure of quality control by permitting assessment of
the reproducibility of repeated maneuvers. Reliable measurements should
have at least three flow-volume curves that can be closely superimposed.
Examination of the inspiratory flow-volume curve is helpful when flow
obstruction derives from the extrathoracic airways, most commonly in the
larynx or upper trachea. These often useful parameters are not always
included in the flow-volume curves reported by standard spirometers.
Flow-volume patterns in upper-airway obstruction are discussed in detail
separately. (See "Flow-volume loops".)
Use in asthma Primary care providers should consider the use of office
spirometry in the evaluation and management of their patients with
asthma. Spirometry can be used to support a diagnosis of asthma by
demonstrating reversible airflow obstruction. This is particularly helpful in
children with isolated symptoms (eg, persistent cough, exercise
intolerance) or atypical presentations. In such patients, spirometry may

also guide the clinician to an alternative diagnosis (eg, restrictive lung

disease). (See "Asthma in children younger than 12 years: Initial
evaluation and diagnosis".)
Once a diagnosis of an obstructive disorder has been made, the
reversibility of the obstruction can be assessed by measuring FEV1 before
and after inhalation of a bronchodilating agent (eg, albuterol). As a
general rule, individuals without bronchial hyperreactivity have a <5
percent increase in FEV1 after inhalation of a bronchodilator [6]. A
postbronchodilator increase in FEV1 of >12 percent constitutes a
reversible obstructive lung defect and supports a diagnosis of asthma.
However, this definition for bronchodilator response (BDR) positivity was
established primarily in adults. An increase in FEV1 of 8 percent may be
a better definition for BDR in children, although it remains an insensitive
test [7-9]. The degree of reversible obstruction can vary from one visit to
the next. Some children may have technically normal flows that are still
less than 100 percent predicted. Bronchodilators can produce
improvement in such children who may have flows of >110 percent
predicted as their normal values. A bronchodilator challenge in this
circumstance may also produce enough improvement to confirm
reversible airway obstruction and indicate asthma. Other features of
asthma, such as clinical response to bronchodilators, must be taken into
account in making the diagnosis in children with mild asthma, rather than
reliance on changes in lung function after a bronchodilator alone.
Monitoring of asthma with spirometry, used in conjunction with daily
symptoms and exacerbation frequency, is also useful in evaluating
response to therapy and changes in asthma severity over time in children
with asthma [10]. Performance of spirometry at the start of treatment and
during the first six months of follow-up were both associated with a
decreased risk of hospitalization in the subsequent year in 27,193 Danish
children aged 6 to 14 years with asthma [11]. Regular measurements in
children with uncomplicated asthma are recommended by multiple
asthma guidelines, such as the National Asthma Education and Prevention
Program (NAEPP) and Global Initiative for Asthma (GINA) guidelines.
The midexpiratory flows measure (FEF25-75%), while highly variable in
repeat measurements, is sometimes a sensitive parameter to indicate an
obstructive defect since it may be reduced in patients who are without
symptoms and have normal FEV1 and PEFR [5].
Barriers to performance of spirometry in the primary care setting include
lack of time and training, particularly in interpretation of results [12].

Peak expiratory flow rate (PEFR) The PEFR measurement (often

referred to as the peak flow measurement), unlike full spirometry, requires
only a short expiratory blast, without the subject having to sustain a
prolonged expiratory effort, and is therefore feasible for younger children
four to six years of age. Typically, the highest of three PEFRs is reported.
The portability and ease of use of inexpensive versions of the Wright Peak
Flow Meter have made this device commonplace in the primary care
setting and the home.
PEFR meters are not "the poor man's spirometer" and have several
important limitations [5,13,14]. The measurements obtained by PEFR
meters are highly effort dependent and can be manipulated by children
[15]. In addition, intrapersonal variability can be substantial and is
particularly affected by circadian rhythms, although diurnal variability may
also indicate poor control. Finally, because mini peak flow meters are not
precise tools, wide variation of recorded PEFR can be observed between
devices, even of the same brand. Thus, measurements performed by
devices other than those customarily used by the patient should be
interpreted with caution.
Peak flow meters have a limited role in establishing the diagnosis of
asthma in the office. However, they are useful in gauging the severity of
asthma exacerbations, both by comparing PEFR measurements
withnormative data (table 2) and, more importantly, to pre-established
baseline ("personal best") values. Such PEFR measurements are
commonly used to assist in determining levels of interventions according
to predetermined asthma management plans. The optional use of PEFR
has also been incorporated into the NAEPP guidelines for asthma
management [1]. The use of PEFR monitoring in asthma is discussed in
detail separately. (See"Peak expiratory flow rate monitoring in asthma".)
Low-cost electronic handheld spirometers that measure FEV1 and PEFR are
now available for use in the home setting [16-19]. The addition of FEV1, a
more reliable spirometric parameter, to PEFR improves individual
monitoring without significantly increasing cost.
Bronchial challenge tests Bronchial challenge, or
bronchoprovocation, tests are designed to provoke an asthmatic response
in children suspected of having bronchial hyperreactivity. Methacholine,
exercise, and/orcold air may be used as the challenge agent. Bronchial
challenge tests are performed when there is uncertainty about the
diagnosis of asthma. Exercise challenges are particularly useful to uncover
exercise-induced airway reactivity, a common and often underdiagnosed
condition in childhood asthma. Bronchial challenge testing should be

performed only in specialized centers [1,20]. In addition, because it has

the potential to induce severe bronchospasm, bronchial challenge testing
requires the presence of staff who are experienced in managing acute
airway obstruction. Bronchial challenge tests are covered in greater detail
separately. (See"Bronchoprovocation testing".)
Spirometry in the care of cystic fibrosis FEV1 is a key outcome
measure in CF. It is routinely used to monitor the rate of progression of the
lung disease, the need for interventions such as the administration of
antibiotics or new drugs, and the effectiveness of such interventions.
(See "Cystic fibrosis: Clinical manifestations of pulmonary disease",
section on 'Pulmonary function'.)
LUNG VOLUME MEASUREMENT Lung volume measurement is
typically undertaken in specialized centers. The measurement of lung
volumes is important in clinical conditions in which a restrictive lung
defectand/or air trapping may be present. It is also important when
addressing possible diffusion capacity defects. The partitioning of lung
volumes is depicted in the figure (figure 1). (See 'Diffusion capacity
measurement'below.)
Methods There are two conventional methods of measuring lung
volumes in children: whole-body plethysmography and gas dilution
(usually with helium and, less frequently, by nitrogen washout). Both
methods measure the functional residual capacity (FRC), which is the
residual air in the lung at the end of exhalation during tidal breathing
(figure 1). The thoracic gas volume (TGV) measured equals FRC because
the measurement is begun at end expiration, after a stable baseline endexpiratory volume is achieved. The FRC is unobtainable by spirometry,
since it includes the residual volume (RV). The use of spirometry together
with measures of FRC allows division of lung volumes, as depicted in the
figure (figure 1). Demonstration of reduced total lung capacity (TLC) is the
gold standard for the diagnosis of restrictive respiratory disease in both
adults and children.
Plethysmography Plethysmography involves placing the child inside a
whole-body plethysmograph or "body box," a sealed structure similar in
appearance to a telephone booth. This is typically done with the child
alone, although the measurements can be performed with the child
seated on the lap of a parent. The plethysmograph is tightly sealed, and
the child is asked to breathe normally at tidal volume (TV) through a
mouthpiece.
The TV is measured, and the mouthpiece is briefly occluded by a shutter
at end expiration (FRC). With the child panting against the closed shutter,

pressure oscillations are simultaneously measured at the mouthpiece and

within the plethysmograph. This maneuver results in alternating
compression and decompression of the intrathoracic gas, which is
measured at the mouth and within the box. By employing Boyle's law,
which states that the product of pressure and volume remains constant in
a closed system (P1V1 = P2V2), the FRC is calculated.
Plethysmography requires cooperation on the part of the subject and is
therefore difficult to obtain in children younger than six years. Reliance on
complex maneuvers, such as panting against a closed shutter, is the
major limitation. In addition, some children find enclosure within the
plethysmograph frightening.
Plethysmography measures the total TGV, including areas not
communicating with the central airways (eg, cysts, areas distal to airway
obstruction), while gas dilution measures only those areas of the lungs in
direct communication with the measurement apparatus. Dilution
techniques, therefore, will underestimate FRC in conditions in which there
is significant air trapping. Thus, plethysmography is preferred in
obstructive conditions, in which air trapping may occur [20].
Gas dilution The gas dilution methods of lung volume determination
are based upon the assessment of helium or nitrogen concentrations and
can be done either as a single breath measurement or, more commonly,
with multiple breaths. The helium dilution method is more commonly
used. Gas dilution methods require less cooperation from the child,
compared with plethysmography. These methods are a good alternative
for patients who cannot physically fit in a plethysmograph (eg, children
confined to wheelchairs) or those who feel too claustrophobic when sitting
in the body box. Gas dilution using a sealed mask applied to the face can
also be used in children whose buccal musculature is too weak to maintain
a seal around a mouthpiece.
In the multiple breath helium dilution method, the subject inhales a gas
mixture containing a known concentration of helium in a known volume;
the subject continues to inhale and exhale into a closed circuit until
equilibrium is obtained. FRC is derived from the proportionate change of
the helium concentration before and after equilibrium is reached (diluted
by the gas inside the chest).
Multiple breath nitrogen washout is performed via an open circuit
measurement by having the child breathe 100 percent oxygen for several
minutes until the nitrogen content of the exhalate is less than 1 percent,
at which point virtually all the nitrogen in the lung has been exhaled into
the spirometer. A rapid nitrogen analyzer measures the exhaled nitrogen

in each exhalate as it is "washed out" with the 100 percent oxygen being
inhaled. The volume of exhaled nitrogen is measured throughout the
procedure. FRC can be calculated by dividing the total volume of nitrogen
obtained by the difference in concentrations obtained.
Clinical application and interpretation
Restrictive disease Restrictive lung defects are defined by reduction
in functional lung volumes and can only be confirmed by such
measurements. In these conditions, the TLC is reduced to below 80
percent of that predicted by age, height, and gender. The RV remains
unchanged with hypotonia, or even increased in cases of chest wall
disease. Thus, the RV/TLC ratio is increased in children with these
disorders, which mainly affect inspiratory, or vital capacity (VC).
The most common pathologic conditions in which lung volume
determination is useful include:
Intrinsic lung diseases, such as interstitial pneumonias
Chest wall pathologies (eg, scoliosis)
Neuromuscular diseases (eg, Duchenne muscular dystrophy)
In restrictive defects caused by intrinsic pulmonary disease, the RV is
often reduced as well, resulting in a normal RV/TLC ratio. In restrictive lung
defects caused by neuromuscular weakness and chest and spine
deformities, the RV remains almost normal and the RV/TLC ratio is
increased (table 1).
Obstructive disease Lung volume measurements are not needed to
define obstructive defects, although such defects can lead to air trapping,
defined as an increased RV/TLC ratio in the setting of airway obstruction
(a reduced FEV1/FVC ratio). When air trapping is present, the TLC can be
normal or increased, the VC is normal or decreased, and the RV is
increased. The latter changes can be the earliest parameters detected in
early airway pathologies, such as cystic fibrosis (CF). Reduced
VC and/or symmetrically reduced VC and FEV1 should prompt lung volume
measurement.
DIFFUSION CAPACITY MEASUREMENT Diffusion capacity is typically
measured in specialized centers because of the cost and complexity of the
required equipment. The diffusing capacity of the lungs for carbon
monoxide (DLCO) and alveolar volume (VA) are measured in conditions in
which impairment of gas diffusion across the alveolar-capillary membrane
or a reduction in the alveolar-capillary surface area is suspected (eg, in

children with exercise intolerance unrelated to bronchospasm, especially

when associated with oxyhemoglobin desaturation, unexplained dyspnea
or hypoxemia, known interstitial lung disease, or pulmonary fibrosis). The
DLCO is used diagnostically to detect the presence of diffusion
abnormalities when diseases of the pulmonary interstitium or vasculitis
are suspected. It is used therapeutically to track effects of interventions
for those diseases or side effects of therapies known to cause pulmonary
fibrosis.
DLCO and DLCO/VA are reduced in intrinsic lung disease, such as the
interstitial lung diseases and idiopathic pulmonary fibrosis as well as in
pulmonary fibrosis secondary to cytotoxic or radiation therapy. Less
frequently, pulmonary edema and pulmonary vascular diseases, including
vasculitis associated with rheumatologic disease, can also reduce the
DLCO. The DLCO is increased above the normal range in pulmonary
hemorrhage. Diffusion capacity testing is not frequently performed in
children; the technical complexity of its performance limits its use to the
older child. The DLCO test is discussed in greater detail separately.
(See "Diffusing capacity for carbon monoxide".)
RESPIRATORY MUSCLE PRESSURE
MEASUREMENTS Determinations of respiratory muscle pressures are
typically measured in specialized centers. These measurements evaluate
the global strength of the inspiratory muscles (maximal inspiratory
pressure [PImax]) and expiratory muscles (maximal expiratory pressure
[PEmax]). The tests consist of a forceful inhalation and exhalation into
tubing connected to a pressure manometer. The values obtained are
compared with normative data for subjects of similar height, age, and
gender.
These tests are useful in determining whether decreases in expiratory
flows or lung volumes are caused by weakness of various respiratory
muscles. They are particularly valuable to assess progression of muscle
weakness in children with progressive neuromuscular disorders, such as
Duchenne muscular dystrophy, since they can help determine when
therapies such as assistance with coughing should be instituted [21].
These tests are discussed in greater detail separately. (See "Tests of
respiratory muscle strength" and "Respiratory muscle weakness due to
neuromuscular disease: Clinical manifestations and
evaluation" and "Clinical features and diagnosis of Duchenne and Becker
muscular dystrophy".)
EXHALED NITRIC OXIDE Attention has focused on biomarkers that
reflect pathologic processes, such as airway inflammation. The most

widely studied of these measures is fractional exhaled nitric oxide (FeNO

or eNO) [22,23]. Increased levels of this gas reflect the degree of
eosinophilic airway inflammation in asthma and atopy. Altered levels of
exhaled FeNO are also seen in other diseases. FeNO measurement is
easily performed, even in preschool age children. Measurement of nasal
FeNO is useful for the diagnosis of primary ciliary dyskinesia, but FeNO is
not a reliable tool for assessing inflammation in cystic fibrosis (CF). The
measurement of FeNO and its role in the diagnosis and management of
asthma is discussed in greater detail separately. (See "Exhaled nitric oxide
analysis and applications".)
EVALUATION OF PULMONARY FUNCTION IN EARLY CHILDHOOD
AND INFANCY Spirometry is usually difficult to obtain in children
younger than six years of age. However, in one study, technically
acceptable and reproducible spirometry was performed by experienced
pediatric pulmonary function technicians in more than 80 percent of 307
children between the ages of three and six years [24]. Technical standards
and reference data differ from those used for older children and adults;
age-specific standards must be used [25]. In this young age group, forced
expiratory volume in one second (FEV1) is often more than 95 percent of
predicted. An alternative index to follow that is more sensitive is the
forced expiratory volume at 0.5 seconds (FEV0.5). The advent of interactive
software for incentive spirometry may facilitate performance of spirometry
in preschool children [26].
Alternative measurements that require less patient cooperation have been
developed for use in young children because of the difficulties in obtaining
reliable forced expiratory maneuvers in this age group [27,28]. Of these,
respiratory system resistance (Rrs) is the most commonly evaluated and
can be assessed by whole body plethysmography, the interrupter
technique (R[int]) [25], or the forced oscillation technique [25,29-31].
None of these measurements are widely available. The uses and
limitations of techniques are reviewed in a statement by the American
Thoracic Society (ATS) [25].
Respiratory morbidity is frequent in children younger than two years,
making evaluation of pulmonary function all the more important in these
children. Significant advances in the assessment of spirometry and
plethysmography in this age group have been made since the 1990s [32].
These techniques, however, are beyond the scope of this review, since the
need for sedation, expensive equipment, and a high level of training limits
them to a few specialty centers.

PREOPERATIVE EVALUATION Lung function testing, including

maximal respiratory pressures and lung volumes in patients who have
known restrictive lung disease, and including spirometry in patients with
chronic obstructive lung diseases, such as cystic fibrosis (CF), can help
anticipate which patients may have a more difficult time with
extubation and/or require prolonged ventilatory assistance.
INFORMATION FOR PATIENTS UpToDate offers two types of patient
education materials, "The Basics" and "Beyond the Basics." The Basics
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patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching
on "patient info" and the keyword(s) of interest.)
Basics topic (see "Patient information: Breathing tests (The Basics)")
SUMMARY
Pulmonary function tests (PFTs) can measure obstructive, restrictive, and
diffusion defects and respiratory muscle function. Measurements of flow
and volume are most useful in the office setting. Spirometry, which
provides both these measures, requires neither sophisticated technology
nor expensive equipment, is easily interpreted, and is reliable when
performed correctly. (See 'Introduction' above.)
The important parameters derived from spirometry include indices of
flow, including forced expiratory volume in one second (FEV1), flow
between 25 and 75 percent of the vital capacity (FEF25-75%), also known
as the maximal midexpiratory flow rate (MMEFR), and peak expiratory
flow rate (PEFR) (table 1). Indices of volume are also measured, including
forced vital capacity (FVC). (See 'Measured parameters'above.)
FEV1, FEF25-75%, and PEFR are decreased in obstructive disorders. FVC
typically is decreased in restrictive disorders and in obstructive diseases
where air trapping is substantial. An FEV1/FVC ratio >85 percent suggests
that the observed decrease in flow is due to volume reduction rather than

airway obstruction and requires direct lung volume assessment for

confirmation. (See 'Interpretation' above.)
Spirometry can be used to support a diagnosis of asthma by
demonstrating reversible airflow obstruction. Spirometry is also helpful in
monitoring the response to long-term therapy and changes in the degree
of obstruction over time. PEFR, as measured by a peak flow meter, may
also be used to gauge the severity of asthma exacerbations, provided that
caretakers and providers understand the limitations of peak flow meters
(table 2). (See 'Use in asthma' above.)
Lung volume measurement is typically undertaken in specialized
centers. The measurement of lung volumes is important in clinical
conditions in which a restrictive lung defect and/or air trapping may be
present. It is also important when addressing possible diffusion capacity
defects. There are two conventional methods of measuring lung volumes
in children: whole-body plethysmography and gas dilution. Both methods
measure the functional residual capacity (FRC), which is the residual air in
the lung at the end of exhalation during tidal breathing (figure 1). This
value is unobtainable by spirometry. Restrictive lung defects are defined
by reduction in functional lung volumes and can only be confirmed by
such measurements. In these conditions the total lung capacity (TLC) is
reduced to below 80 percent of that predicted by age, height, and gender.
(See 'Lung volume measurement' above.)
Additional types of pulmonary function tests that are typically performed
at specialized centers include measurement of diffusing capacity of the
lungs for carbon monoxide (DLCO), respiratory muscle pressure, and
fractional exhaled nitric oxide. (See 'Diffusion capacity
measurement' above and 'Respiratory muscle pressure
measurements' above and 'Exhaled nitric oxide' above.)
Alternative measurements that require less patient cooperation have
been developed for use in young children because of the difficulties in
obtaining reliable forced expiratory maneuvers in this age group. Of these,
respiratory system resistance (Rrs) is the most commonly evaluated and
can be assessed by whole body plethysmography, the interrupter
technique (R[int]), or the forced oscillation technique. (See'Evaluation of
pulmonary function in early childhood and infancy' above.)