Lung Volumes & Capacities

Lung volumes & Capacities

Lung volumes and lung capacities refer to the volume of air associated with different phases of the respiratory cycle

Lung volumes are directly measured

Lung capacities are inferred from lung volumes
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Objectives
Define the following: Four volumes TV IRV ERV RV
n n

Define the following: Four capacities IC VC FRC TLC

n n

Also Closing Capacity

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Typical volume/time tracing

A capacity is the sum of two or more volumes.

Measurement
- estimating the volume of gas inside the
thorax

- most common methods : 1. Gas dilution tests. 2. Body plethysmography (Body Box).

Gas dilution tests

Person breathes nitrogen or helium gas through a tube for a specified period of time The final dilution of the gas is used to calculate the volume of air in the thorax

* Helium doesnt readily diffuse across the alveolar

capillary membrane

Gas dilution tests Disadvantages :

- It is sensitive to errors

- Leakage of gas
- Failure to measure the volume of gas in lung bullae : because helium may not mix with all parts of the lung .
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Body Plethysmography

Body Plethysmography

The most accurate way

The patient sits inside a fully enclosed rigid box and
breath through mouthpiece connected through a shutter to the internal volume of the box shutter (like panting), causing their chest volume to expand and decompressing the air in their lungs

The subject makes respiratory efforts against the closed

while breathing in and out again into a mouthpiece. The

volume of all gas within the thorax can be measured by Changes in pressure inside the box and allow determination of the lung volume.

PFT II

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 Using

the data from the requires use of Boyles Law.

plethysmography

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.

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By this technique we will be able to know

Residual volume (RV) Tidal volume (TV) Total Lung Capacity (TLC) Expiratory reserve volume (ERV) Inspiratory Reserve Volume (IRV) Inspiratory capacity (IC) Functional residual capacity (FRC) Vital Capacity (VC)

Tidal volume (TV)

It is the volume of air inspired or expired with each breath during normal breathing

An up deflection is inspiration. A down deflection is expiration.

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Tidal volume

Normal : 400-700ml (7ml/kg)

Tv varies with the build & age of the individual and the depth of respiration

Decreased in severe RLD

Minute volume (MV) = TV x RR Measurement during A/N : Using wright respirometer The instrument records for one minute MV can be measured directly TV is calculated by dividing MV by RR
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Inspiratory Reserve Volume (IRV)

It is the maximal volume of air inspired with effort in excess of tidal volume

IRV: From TV to TLC

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Expiratory reserve volume (ERV)

It is the maximal volume of air exhaled from the resting end-expiratory level or volume expired by active expiration after passive expiration.

ERV: From TV to RV

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ERV

Decreased in RLD

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Residual volume (RV)

It is the volume of air remaining in the lungs at the end of maximal expiration.

PFT II

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RV

Normal 25% of TLC Increased

1. Br.Asthma : airway narrowing with air trapping 2. Emphysema : loss of elastic recoil

Decreased - pulmonary fibrosis :Increased elastic recoil

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Vital Capacity
volume of gas measured on complete expiration after complete inspiration without effort

VC= TLC RV or VC= IRV+TV+ERV

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VC Decreased 1.OLD 2. RLD

( VC < 15 ml/kg (and VT < 5ml/kg)

indicates likely need for mechanical ventilation

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Inspiratory capacity (IC):

It is the maximal volume of air inspired from resting expiratory level

IC= IRV+TV.

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Total Lung Capacity (TLC)

It is the total volume of air within the lung after maximum inspiration. (the maximum volume of air that the lung can contain)

TLC = FVC + RV OR TLC = RV + ERV + TV + IRV

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TLC

Increased 1. Br.Asthma : airway narrowing with air trapping 2. Emphysema : loss of elastic recoil Decreased - pulmonary fibrosis :Increased elastic recoil - muscle weakness, Obesity
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Functional Residual Capacity (FRC)

It is the volume of air remaining in the lungs at the end of resting (normal) expiration.

FRC = RV + ERV.

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FRC

Increased (>120% of predicted) decreased elastic recoil: Emphysema air trapping: B.Asthma, bronchiolar obstruction Decreased intrinsic ILD by upward movement of diaphragm (obesity, painful thoracic or abdominal wound)
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Lung volumes & capacities

PFT II

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Lung Volume in Obstructive Lung Disease

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Obstructive Lung Disease

Narrowing and closure of airways during expiration tends to lead to
gas trapping within the lungs and hyperinflation of the chest.
Air trapping increase in RV Hyperinflation increases TLC

RV tends to have a greater percentage increase than TLC RV/TLC ratio is therefore increased (nl 20-35%) Gas trapping may occur without
hyperinflation: (increase in RV & normal TLC)

PFT II

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 Gas trapping and airway

closure at low lung volume cause the patient to breath at high lung volume so FRC (RV+ERV) increased

This will prevent airway

closure and improve ventilation-perfusion relationship

It will reduce mechanical

advantage of respiratory muscles and increases the work of breathing

PFT II

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Obstructive Lung Disease

RV TLC RV/TLC FRC VC

increased Nl /increased increases increased decreased

*Air trapping :Normal TLC with increase RV/TLC *Hyperinflation: Increase in both TLC and RV/TLCl/
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Lung Volume in Restrictive Lung Disease

PFT II

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Reduction in TLC is a cardinal feature

1. In Intrinsic RLD (Interstitial Lung Disease)

TLC will decrease RV will decrease because of increased elastic recoil (stiffness) of the lung and loss of the alveoli. Breathing take place at low FRC because of the increased effort needed to expand the lung . RV/TLC normal

PFT II

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2. In extrinsic RLD (chest wall disease :kyphoscoliosis or neuromuscular disease:ALS,MG)

TLC is reduced either because of mechanical limitation to chest wall expantion or because of respiratory muscle weakness RV is Normal because Lung tissue and elastic recoil is normal So RV/TLC ratio will be high

Breathing take place at low FRC because of the increased effort needed to expand the lung .

PFT II

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Restrictive Lung Disease:

RLD Intrinsic & severe chest wall dis (pleural and skeletal) Extrinsic RLD TLC decreased RV normal RV/TLC High VC decreased FRC decreased

TLC RV RV/TLC FRC VC

decreased decreased normal decreased decreased

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3. In combined obstructive and restrictive disease(e,g.sarcoidosis ,COPD+IPF)

Obstructive pattern on spirometry and Reduced lung volume 4. In equivocal spirometry result : e,g.when FEV1,FVC at lower limit of normal If TLC or RV raised the diagnosis is obstructive lung disease
PFT II 38

Obstructive Lung dis.

RLD Interinsic

RLD Extrinsic

FEV1 FVC FEV1/FVC

RV
TLC

RV/TLC
VC FRC
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Functional Residual Capacity

Volume of air that remains in the lungs at the end of normal expiration. FRC = ERV + RV Facilitates uninterrupted oxygenation and co2 removal across the alveolo-capillary membrane in-between breaths. Normal value : male 3330ml female- 2300ml

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FRC

Increases : Asthma, c/c bronchitis, PEEP Decreases : induction of a/n, post-op

Other Factors : Posture, age, body habitus, pregnancy FRC & Anaesthesia : 1. Pre-oxygenation 2. Induction of a/n 3. post-operative period

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Pre-oxygenation

Essential to any sequence of difficult airway management under GA Provides an O2 reservoir within the lung and body tissue to tide over the apnoeic spell needed during intubation FRC - Main reservoir; 30ml/kg

Resting metabolic O2 requirement = 250ml/mt Normally in room air FRC = N2 + O2 volume of O2 = 500ml So a patient breathing room air can withstand apnoea for about 2 minutes without desaturating
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Pre-oxygenation

Denitrogenation : spontaneously breathing 100% O2 for 5 minutes via a tightly fitting face mask. Urgent situation : 4 maximal capacity breaths FRC =2100ml (70kg) = 2100 ml O2 Patient can withstand apnoea for upto 8 minutes without desaturating Obese adult will desaturate to less than 90% in less than 3mts.
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FRC during intraop period

FRC reduced during a/n & surgery Reduced by 20% during a/n induced with thiopentone & maintained by inhalational agents & IV narcotics Irrespective of whether breathing is spontaneous or controlled Magnitude of reduction is predominantly determined by body habitus In morbidly obese FRC can reduce by as much as 50% following induction of a/n
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Mechanism of reduced FRC : - loss of outward elastic recoil of the chest wall
- During expiration chest wall is drawn inwards to a a greater extent FRC - Inspiratory muscle tone of the diaphragm, scmt, scalene & IC muscles is lost following induction - Cephalad displacement of diaphragm& a decrease in cross-sect. area of thorax both contribute reduced FRC

Consequences :
-atelectasis - early airway closure - altered pulmonary mechanics ASSOCIATED V/Q MISMATCH

FRC during intraop period

Reduction in FRC assoc. with a/n can be partially reversed with : 1. CPAP 2. PEEP 3. 30 Head up tilt

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FRC & POST-OP PERIOD

Reduced FRC is the causative factor for post-op hypoxemia, atelectasis & pnumonia

Impact of adverse effects minimised by : - active lung expansion manoevers - good post-op analgesia

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CLOSING CAPACITY

The lung volume ( during expiration) at which the small airways begin to close and therefore prevent any further expulsion of gas from related alveoli. Measured by single breath nitrogen washout technique.

CLOSING CAPACITY

Single breath N2 washout tech. - breathing room air the subject

slowly expires to residual volume - slowly takes a single breath of oxygen to max. inhalation - Breath is held for a few seconds - Then slowly & evenly exhaled.

During the last phase the instantaneous nitrogen conc. & volume of the expirate are recorded & a characteristic curve is obtained.
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CLOSING CAPACITY

4 PHASES :
I -Dead space gas II -Mixed dead space & alveolar gas III-Mixed alveolar gas from all alveoli IV-Sudden rise in conc of N2.

CC - VOLUME AT WHICH PHASE IV BEGINS

PFT II 51

CLOSING CAPACITY

Relationship between CC & FRC : - If CC rises above the FRC some

airways will be closed during part or whole of the normal range of ventilation.

areas of lung will not be fully oxygenated and the arterial O2 will fall

- so the blood passing through the closed

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CLOSING CAPACITY

Factors increasing CC :

1. Age :CC progressively increases from

late teens onwards CC=FRC - in the 60s, - in the 40s in supine subjects 2.Position : CC increases in supine & head low 3. smokers, obesity, rapid IV transfusions, c/c bronchitis, left ventricular failure, MI 4. Post-op period : imp. Cause of post-op hypoxemia
PEEP increases the FRC above CC thereby increasing PaO2

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DEAD SPACE
A) Anatomical Dead Space (VD Anat) B) Physiological Dead Space (VD Phys)

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Anatomical Dead Space (VD Anat)

Volume of the respiratory passages extending from the nostrils down to the respiratory bronchioles(not including) No exchange of gas b/w blood & air

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VD Anat

Normal volume 150ml Varies with:

1) Age : old age- 200ml 2) sex : young women ~ 100ml 3) Jaw position : depression of jaw with flexion of headdec. VD by 30ml Protrusion of jaw with extensionof head inc. VD by 40ml Pneumonectomy & tracheostomy dec VD
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Physiological Dead Space (VD Phys)

Fraction of the TV which is not available for gaseous exchange VD Phys = VD(Anat) + VD (Alveolar)
Alveolar Dead Space : - wasted ventilation occuring in zones of lung with high V/Q ratio If there is no blood flow to a particular zone ( eg.in pulmonary embolism) then all the ventilation to that zone is wasted.

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VD Phys

1.
2. 3.

VD Phys increased in :
Old age In upright position With large TV High RR When inspiratory time is reduced to 0.5 sec orless during controlled ventilation Bronchial asthma & c/c bronchitis Pulmonary embolism Controlled hypotension
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4.
5.

6. 7. 8.

Normally : VD(Anat) = VD(phys)=1/3rd TV Relationship b/w VD(Anat) & VD(phys) is constant across TV VD/VT = 0.25- 0.4

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Effect of anaesthesia onVD General rule : VD/VT & VD(physio) incr. Intubation : VD( physio) dec. by 70ml Controlled ventilation : VD/VT 0.3 0.45

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Apparatus Dead Space

Volume of gas contained in any anaesthetic apparatus b/w the patient and that point in the system where rebreathing of exaled co2 ceases to occur

E.g. expiratory valve in magill system; side arm in ayres T piece May add as much as 125 ml of dead space to the patient
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Alveolar ventilation( VA)

Definition : that part of the MV which takes part in gas exchange Normal : 2.0-2.6 l/min/m2 3.5-4.5 l/min in adults Pulmonary factor controlling the excretion of co2 Directly related to TV, VD(phy) & RR VA = (TV Vdphy) x RR
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Alveolar ventilation( VA)

Clinical assessment : most important for a/n Observation of reservoir bag, movt of chest & abdomen, rate of resp. & measurm. Of MV

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