PULMONARY FUNCTION TESTING

Wyka Chapter 13 Various AARC Clinical Practice Guidelines

Purposes of Pulmonary Tests

  

Is lung disease present?  If so , is it reversible ? If so, what type of lung disease is present? How bad is the problem?  Is reha bilit at io n a n o pt io n? Is there more than one lung disease present? Obstructive Diseases characterized by airflow limitat ions  Ast hma; E mp hyse ma ; Chro nic Bro nc hit is Restrictive Diseases characterized by a decrease in lung vo lumes  Pu lmo nar y Fibro sis; Severe Kyp ho sc io lo sis; O besit y

General Categories of Lung Diseases

 

Types of PF Tests
 

Tests of Lung Volumes & Capacit ies  FRC; RV ; TLC; IC; VC Tests of Airflow  Sp iro met ry me asures flo wrat es o f e xha led gas ba sed upo n a fo rced exha lat io n  Flo w-vo lu me lo o ps creat es a visua l p ict ure show ing t he flo wrat e at any given lung vo lume Carbon Monoxide Diffusing Capacit y  Measure s ho w we ll ga s ca n d iffu se acro ss t he a lve o lar-cap illar y me mbr a ne  This va lu e is decrea sed in E mp hyse ma & in Pu lmo nar y Fibro sis

What is Considered Abnormal?



Example of a Nomogram

Normal values for volumes, capacit ies, diffusio n & flowrates are based upon a persons;  Age  He ig ht  Gender Nomograms provide an easy way of determining a persons expected values

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When is a value abnormal?

    

Normal = 80 120% of predicted Mild impairment = 65 79% predicted Moderate impairment = 50 64% Severe impairment = 35 49 % Very Severe = <35%

How to calculate % predicted



% predicted =

measured value X 100 predicted value

How Lung Volumes Change in Disease

What causes Restrictive Changes?

HOW VOLUMES & CAPACITIES CHANGE  Restrictive Disorders



  

Vt N or decreased FRC decreased RV decreased TLC decreased

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VC decreased IC - decreased Vt N or increased FRC increased RV increased N or increased VC N or decreased IC N or decreased

Obstructive Disorders


    

Types of flowrates


Simple Spirometry  FVC fo rced vit a l capa c it y  Usua lly e xp irat ory ma neu ver  FEV1 amo unt o f vo lu me exha led in 1 sec.  FEF200-1200 average speed o f gas be ing exhaled after the first 200ml up to 1200 ml  Lo o ks at qualit y o f a ir flo w in t he larger airways

FEF25 -75% - average speed of gas co ming out of the lungs after the first 25% up to 75% of the VC  Lo o ks at t he qua lit y o f a ir flo w fro m t he smaller airways  Goo d ind e x o f sma ll a irwa ys d isease seen in asthma and emphysema

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Calculating Simple Spirometric Data

  

What is FVC? What is FEV1? What is FEV1/FVC ratio? To calculate; Observed FEV1 X 100% Obser ved FVC FEV1% is a good general index of presence of obstruction verses restrict ive disorder

Significance of FEV1%
 

In obstructive disease; FEV1% is decreased In restrict ive disease; FEV1% is increased or normal

Flow-Volume Loops
 

Obtained when a patient does an Expiratory FVC followed by an Inspiratory FVC Inspirat ion is below the x-axis & Expirat ion is above the xaxis Gives a unique visual picture of flows throughout the breathing cycle During the last 25% of exhalat ion (from 75% to 100% of expiratory flow), flowrate is effort independent Allows clinicians to ident ify obstruction on either inspirat ion OR exhalat ion

Significance of Flow-Volume Loops

 

Examples of Flow-Volume Loops

As you can see, each patient type has a distinctive signature pattern.

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Important Data Points on Flow-Volume Loop

FEF25%; FEF50%; FEF75%; FIF25%; FIF50%; FEF75% These points give indications of flow at specific lung volumes

Maximal Voluntary Ventilation

 

Also called MVV or MBC Patient breaths rapidly using breaths greater than a normal Vt but less than IC or FVC Is a test of overall function of respiratory system. Influenced by; Status of respi rato ry muscles Compliance of lung-thora x system Condition of ventilatory contro l mechanisms Resistance offered by airways Normal values in young people is 150-200 l/m. Only decreases of >30% are significant

Significance of MVV


Before & After Bronchodilator Tests

 

Spirometric values (FEV1); FEF200-1200; FEF25-75%; MVV & Flow-vo lume loops can be repeated after giving the patient an SVN tx or MDI with a bronchodilator Improvement is defined as a 20% increase in any observed values

Diffusion Tests
 

Carbon mo noxide (CO) diffusing capacit y DLCO. Most popular type is the single-breath method Patient breathes in to TLC a mixture of 0.3% CO + 10% He + 21% O2 and ho lds breath for about 10 seconds Patient exhales into a small bag where gas concentrations are analyzed

DLCO Calculations


Where; FaCOo = fract io n o f CO at beg inning o f breat h-ho ld

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FICO = fract ion of CO in the reservo ir FAHe = fract io n o f He at t he end-t idal samp le FIHe = fract io n o f He in insp ired gas FACOo = FICO X FAHe FIHe

Significance of DLCO
 

 

Normals vary by as much as 30% Decreased in restrict ive diseases (generally) Alveo lar fibrosis Decreased by space occupying tumors and after lung resect ion Decreased in loss of lung t issue Emphysema

Measuring RV, FRC and TLC

FRC is measured indirect ly using one of the three fo llowing techniques; 1. Body plethysmography (body box) 2. Nitrogen washout study 3. Helium dilut ion  Once FRC is measured, RV and TLC can be calcu lat ed mat hemat ically


1. Body Plethysmography
 

Patient is sealed in a box & ventilates through a mouthpiece wit h a pressure transducer and shutter valve allowing obstruction at the mouthpiece Patient breathes gas fro m the box. At FRC, the shutter is closed; the patient pants for 20-40 breaths/min against an obstruction As this occurs, pressure is measured at the proximal airway AND wit hin the box at the same time Boyles law is used to determine the final vo lume in the box:  P1V1 = P2V2 Where;  P1 = Orig ina l pressure in t he bo x (760 torr)  V1 = Orig ina l vo lu me in t he bo x (1,000L)  P2 = Increased pressure in t he bo x as a resu lt o f chest expansio n  V2 = Fina l vo lu me in t he bo x

Example; (760 mmHg)(1000L)=(760.2 mmHg) x (760 mmHg)(1,000L) = x 760.2 mmHg x = 999.737 L Difference between V1 & V2 change in volume in the patients thorax

1,000 L - 999.737 L = .263 L

As the patient pants against an obstruction, the volume in the thorax increases & the pressure in thorax is decreased. Using Bo yles law again;  Pa1Va1 = Pa2Va2  Where Pa1 = pro x airwa y pressure at rest ing FRC( t his equa ls 760 mmHg)  Va1 = vo lu me o f FRC

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Pa2 = pressure in airway after inspiring against an obstruction Va2 = Final vo lume in thorax (# from previous equation)

(Pa1)(Va1) = (Pa2)(Va1 + V) (760 mmHg)(x) = 700 mmHg (x + .263) 760 mmHg x = 700 mmHg x + 184.1 60 mmHg x = 184.1 mmHg L 60 mmHg 60 mmHg x= 3.07 L this is the patients FRC

Body Plethysmography is popular since it is the most accurate method for determining FRC  Ot her met ho ds do not accurat ely measure t rapped gas co mmo nly present in patients wit h COPD

2. Nitrogen Washout for FRC

  

 

Patient connected to breathing circuit & inspires 100% O2. Total vo lume of exhaled air is collected separately Test normally lasts for about 7 minutes or until expired N2 is 1% to 2.5% Since nitrogen makes up about 80% of FRC on room air, the vo lume of nitrogen is the total exhaled gas will equal about 80% of FRC Total vo lume exhaled into bag is measured along with N2 concentration in the bag
Example;  Total volume collected 50 L  Measur ed N2 % 5%  Volume of n itr ogen in bag = 50 x .05 = 2.5 L Example continued; 2.5 L = x . .80 FRC 1 FRC x = 3.125 L (this is the patients FRC)

Problems with Nitrogen Washout  At e lect asis ma y re su lt fro m washo ut o f nit ro gen fro m poo rly ve nt ilat ed lu ng zo nes (obstructed areas)  Eliminat io n o f hypo xic dr ive in CO2 ret ainer s is po ssib le  Undere st imat es FRC due to underve nt ilat io n o f are as w it h t rapped gas

3. Helium Dilution for FRC

 

Since helium is inert, as patients breaths the helium, its vo lume does not decrease since it is not absorbed by the blood. Patient is connected to a rebreathing system and a known vo lume & concentration of helium is added to the system The patient breathes unt il the final He concentration is stable. (About 7 minutes) FRC is calculated using the fo llowing equation;
FRC = (% He initial - % He final) x initial vol. % He final

Wher e % He initia l = 10% % H e final = 3.5 % I nitial vol. = 200 ml = 2,000ml or 2.0 L

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10%

FRC = (% He initial - % He final) x initia l vol. % He final FRC = (10% - 3.5%) x 2.0 L = 3.7 L 3.5%

Problems with Helium dilut ion for FRC are similar to Nitrogen washout problems;  Presenc e o f se vere ly o bst ruct ed airwa ys a s fo und in COPD pat ie nt s t ends to cause poor distribut ion of helium  Leaks in t he syst e m o r pat ie nt w ill c ause erro neo us va lues

ADDITIONAL PULMONARY FUNCTION TEST Determination of Closing Volume

  

   

Closing vo lume is the point during slow exhaled VC maneuver at which small airways begin to collapse In young, healt hy adults is about 10% of VC Closing vo lume increases with age  At age 60 ma y be as hig h as 40% Increases wit h lung disease (COPD) Is a good earlier indicator of small airways disease Single-breath Nitrogen washout study is used to determine Closing Volume Patient breathes in 100% O2 from RV to TLC and slowly exhales back to RV

Single-breath Nitrogen washout curve

Single-breath Phases  Phase 1 N2 % is zero (gas fro m upper airways)  Phase 2 St eep increase in N2 % (gas fro m smalle r airways & alveo lar reg io ns)  Phase 3 Slo w increase in N2% (gas fro m mo st ly alveo lar reg io ns  Phase 4 Clo sing vo lu me (gas fro m ap ices o nly is exhaled N2 % is hig hest in apices)

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CO2 response curve

Patients are connected to a rebreathing circuit and given a mixture of 93% oxygen while CO2 % is gradually increased up to 7% Changes in minute ventilat ion are measured as CO2 concentration is increased. CO2 response is determined by the peripheral chemoreceptors  Decreased respo nse to CO2 is seen in lu ng d isease (COPD pat ient s wit h severe airway obstruction)

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