Pulmonary function testing

Pulmonary function testing (PFT) is a complete evaluation of the respiratory system including patient history, physical examinations, and tests of pulmonary function. The primary purpose of pulmonary function testing is to identify the severity of pulmonary impairment.^[1] Pulmonary function testing has diagnostic and therapeutic roles and helps clinicians answer some general questions about patients with lung disease. PFTs are normally performed by a pulmonary function technician, respiratory therapist, respiratory physiologist, physiotherapist, pulmonologist, or general practitioner.

Pulmonary function testing
Plethysmograph "body box"
MeSH	D012129
OPS-301 code	1-71
MedlinePlus	003853

TLC	Total lung capacity: the volume in the lungs at maximal inflation, the sum of VC and RV.
TV	Tidal volume: that volume of air moved into or out of the lungs during quiet breathing (TV indicates a subdivision of the lung; when tidal volume is precisely measured, as in gas exchange calculation, the symbol TV or VT is used.)
RV	Residual volume: the volume of air remaining in the lungs after a maximal exhalation
ERV	Expiratory reserve volume: the maximal volume of air that can be exhaled from the end-expiratory position
IRV	Inspiratory reserve volume: the maximal volume that can be inhaled from the end-inspiratory level
IC	Inspiratory capacity: the sum of IRV and TV
IVC	Inspiratory vital capacity: the maximum volume of air inhaled from the point of maximum expiration
VC	Vital capacity: the volume of air breathed out after the deepest inhalation.
VT	Tidal volume: that volume of air moved into or out of the lungs during quiet breathing (VT indicates a subdivision of the lung; when tidal volume is precisely measured, as in gas exchange calculation, the symbol TV or VT is used.)
FRC	Functional residual capacity: the volume in the lungs at the end-expiratory position
RV/TLC%	Residual volume expressed as percent of TLC
VA	Alveolar gas volume
VL	Actual volume of the lung including the volume of the conducting airway.
FVC	Forced vital capacity: the determination of the vital capacity from a maximally forced expiratory effort
FEVt	Forced expiratory volume (time): a generic term indicating the volume of air exhaled under forced conditions in the first t seconds
FEV1	Volume that has been exhaled at the end of the first second of forced expiration
FEFx	Forced expiratory flow related to some portion of the FVC curve; modifiers refer to amount of FVC already exhaled
FEFmax	The maximum instantaneous flow achieved during a FVC maneuver
FIF	Forced inspiratory flow: (Specific measurement of the forced inspiratory curve is denoted by nomenclature analogous to that for the forced expiratory curve. For example, maximum inspiratory flow is denoted FIFmax. Unless otherwise specified, volume qualifiers indicate the volume inspired from RV at the point of measurement.)
PEF	Peak expiratory flow: The highest forced expiratory flow measured with a peak flow meter
MVV	Maximal voluntary ventilation: volume of air expired in a specified period during repetitive maximal effort
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Indications

Pulmonary function testing is a diagnostic and management tool used for a variety of reasons, such as:

• Diagnose lung disease.
• Monitor the effect of chronic diseases like asthma, chronic obstructive lung disease, or cystic fibrosis.
• Detect early changes in lung function.
• Identify narrowing in the airways.
• Evaluate airway bronchodilator reactivity.
• Show if environmental factors have harmed the lungs
• Preoperative testing^[2]

Neuromuscular disorders

Pulmonary function testing in patients with neuromuscular disorders helps to evaluate the respiratory status of patients at the time of diagnosis, monitor their progress and course, evaluate them for possible surgery, and gives an overall idea of the prognosis.^[3]

Duchenne muscular dystrophy is associated with gradual loss of muscle function over time. Involvement of respiratory muscles results in poor ability to cough and decreased ability to breathe well and leads to collapse of part or all of the lung leading to impaired gas exchange and an overall insufficiency in lung strength.^[4]

Tests

Spirometry

Main article: Spirometry

 

Spirometry

Spirometry includes tests of pulmonary mechanics – measurements of FVC, FEV₁, FEF values, forced inspiratory flow rates (FIFs), and MVV. Measuring pulmonary mechanics assesses the ability of the lungs to move huge volumes of air quickly through the airways to identify airway obstruction.

The measurements taken by the spirometry device are used to generate a pneumotachograph that can help to assess lung conditions such as: asthma, pulmonary fibrosis, cystic fibrosis, and chronic obstructive pulmonary disease. Physicians may also use the test results to diagnose bronchial hyperresponsiveness to exercise, cold air, or pharmaceutical agents.^[5]

Helium Dilution

Main article: Helium dilution technique

The helium dilution technique for measuring lung volumes uses a closed, rebreathing circuit.^[6] This technique is based on the assumptions that a known volume and concentration of helium in air begin in the closed spirometer, that the patient has no helium in their lungs, and that an equilibration of helium can occur between the spirometer and the lungs.

Nitrogen Washout

Main article: Nitrogen washout

The nitrogen washout technique uses a non-rebreathing open circuit. The technique is based on the assumptions that the nitrogen concentration in the lungs is 78% and in equilibrium with the atmosphere, that the patient inhales 100% oxygen and that the oxygen replaces all of the nitrogen in the lungs.^[7]

Plethysmography

Main articles: Plethysmograph and Lung volumes

The plethysmography technique applies Boyle's law and uses measurements of volume and pressure changes to determine total lung volume, assuming temperature is constant.^[8]

There are four lung volumes and four lung capacities. A lung's capacity consists of two or more lung volumes. The lung volumes are tidal volume (V_T), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), and residual volume (RV). The four lung capacities are total lung capacity (TLC), inspiratory capacity (IC), functional residual capacity (FRC) and vital capacity (VC).

Maximal respiratory pressures

Main article: Respiratory pressure meter

Measurement of maximal inspiratory and expiratory pressures is indicated whenever there is an unexplained decrease in vital capacity or respiratory muscle weakness is suspected clinically. Maximal inspiratory pressure (MIP) is the maximal pressure that can be produced by the patient trying to inhale through a blocked mouthpiece. Maximal expiratory pressure (MEP) is the maximal pressure measured during forced expiration (with cheeks bulging) through a blocked mouthpiece after a full inhalation. Repeated measurements of MIP and MEP are useful in following the course of patients with neuromuscular disorders.

Diffusing capacity

Main article: Diffusing capacity

Measurement of the single-breath diffusing capacity for carbon monoxide (DLCO) is a fast and safe tool in the evaluation of both restrictive and obstructive lung disease.

Bronchodilator responsiveness

When a patient has an obstructive defect, a bronchodilator test is given to evaluate if airway constriction is reversible with a short acting beta-agonist. This is defined as an increase of ≥12% and ≥200 mL in the FEV1 or FVC.^[9]

Oxygen desaturation during exercise

The six-minute walk test is a good index of physical function and therapeutic response in patients with chronic lung disease, such as COPD or idiopathic pulmonary fibrosis.^[10][11][12]

Arterial blood gases

Arterial blood gases (ABGs) are a helpful measurement in pulmonary function testing in selected patients. The primary role of measuring ABGs in individuals that are healthy and stable is to confirm hypoventilation when it is suspected on the basis of medical history, such as respiratory muscle weakness or advanced COPD.

ABGs also provide a more detailed assessment of the severity of hypoxemia in patients who have low normal oxyhemoglobin saturation.

Risks

Pulmonary function testing is a safe procedure; however, there is cause for concern regarding untoward reactions and the value of the test data should be weighed against potential hazards. Some complications include dizziness, shortness of breath, coughing, pneumothorax, and inducing an asthma attack.^[13][14]

Contraindications

There are some indications against a pulmonary function test being done. These include a recent heart attack, stroke, head injury, an aneurysm, or confusion.^[15]

Technique

Preparation

Subjects have measurements of height and weight taken before spirometry to determine what their predicted values should be. Additionally, a history of smoking, recent illness, and medications is taken.

Quality control

In order for the forced vital capacity to be considered accurate it has to be conducted three times where the peak is sharp in the flow-volume curve and the exhalation time is longer than 6 seconds.

Reproducibility of the PFT is determined by comparing the values of forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1). The difference between the highest values of two FVCs need to be within 5% or 150 mL. When the FVC is less than 1.0 L, the difference between the highest two values must be within 100 mL. Lastly, the difference between the two highest values of FEV1 should also be within 150 mL. The highest FVC and FEV1 may be used from each different test. Until the results of three tests meet the criteria of reproducibility, the test can be repeated up to eight times. If it is still not possible to get accurate results, the best three tests are used.^[16]

Clinical significance

Changes in lung volumes and capacities from normal are generally consistent with the pattern of lung impairment.

Spirometry is required for a diagnosis of COPD.^[17]

Interpretation of tests

Classification of COPD based on spirometry^[18]

Severity	FEV1 % predicted
Mild (GOLD 1)	≥80
Moderate (GOLD 2)	50–79
Severe (GOLD 3)	30–49
Very severe (GOLD 4)	<30

See also: Spirometer § History - Interpreting Spirometry

Professional societies such as the American Thoracic Society and the European Respiratory Society have published guidelines regarding the conduct and interpretation of pulmonary function testing to ensure standardization and uniformity in performance of tests. The interpretation of tests depends on comparing the patients values to published normals from previous studies. Deviation from guidelines can result in false-positive or false negative test results, even though only a small minority of pulmonary function laboratories followed published guidelines for spirometry, lung volumes and diffusing capacity in 2012.^[19]

COPD

The Global Initiative for Chronic Obstructive Lung Disease provides guidelines for the diagnosis, severity, and management of COPD.^[20] To determine obstruction in a patient's lungs, the post-bronchodilator FEV1/FVC needs to be <0.7.^[17] Then, the FEV1 percentage of predicted result is used to determine the degree of obstruction where the lower the percent the worse the obstruction.^[18]

Maximum respiratory pressures

Several calculations are needed for what a normal maximum inspiratory (MIP) and expiratory pressure (MEP) is. For males this found by:

${\displaystyle MIP=120-(0.41\times age)}$ 

and

${\displaystyle MEP=174-(0.83\times age)}$ 

To find the lower limit of what is acceptable in males the equations are:

${\displaystyle MIP_{LLN}=62-(0.15\times age)}$ 

and

${\displaystyle MEP_{LLN}=117-(0.83\times age)}$ 

For females, the equations are slightly different. For the normal values this is used:

${\displaystyle MIP=108-(0.61\times age)}$ 

and

${\displaystyle MEP=131-(0.86\times age)}$ 

For find the lower limit of what it should be without impairment this form of the equations is used:

${\displaystyle MIP_{LLN}=62-(0.50\times age)}$ 

and

${\displaystyle MEP_{LLN}=95-(0.57\times age)}$ 

where

• ${\displaystyle MIP}$  = maximum inspiratory pressure in cmH20
• ${\displaystyle MEP}$ = maximum expiratory pressure in cmH20
• ${\displaystyle MIP_{LLN}}$  = maximum inspiratory pressure lower limit of normal in cmH20
• ${\displaystyle MEP_{LLN}}$  = maximum expiratory pressure lower limit of normal in cmH20
• ${\displaystyle age}$  = the patient's age in years^[21]

References

1. Burrows B (May 1975). "Pulmonary terms and symbols: A report of the ACCP-ATS joint committee on pulmonary nomenclature". Chest. 67 (5): 583–593. doi:10.1378/chest.67.5.583. PMID 1126197.
2. "Pulmonary Function Tests" (PDF). American Thoracic Society. Retrieved June 15, 2022.
3. Sharma GD (May 2009). "Pulmonary function testing in neuromuscular disorders". Pediatrics. 123 (Suppl 4): S219–S221. doi:10.1542/peds.2008-2952D. PMID 19420147.
4. Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, et al. (August 2004). "Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement". American Journal of Respiratory and Critical Care Medicine. 170 (4): 456–465. doi:10.1164/rccm.200307-885ST. PMID 15302625.
5. Gafanovich M (June 2010). "Pulmonary Function Test in New York".
6. Hathirat S, Mitchell M, Renzetti AD (November 1970). "Measurement of the total lung capacity by helium dilution in a constant volume system". The American Review of Respiratory Disease. 102 (5): 760–70. doi:10.1164/arrd.1970.102.5.760 (inactive 31 December 2022). PMID 5475674.{{cite journal}}: CS1 maint: DOI inactive as of December 2022 (link)
7. Boren HG, Kory RC, Syner JC (July 1966). "The Veterans Administration-Army cooperative study of pulmonary function: II. The lung volume and its subdivisions in normal men". The American Journal of Medicine. 41 (1): 96–114. doi:10.1016/0002-9343(66)90008-8.
8. DuBois AB, Botelho SY, Bedell GN, Marshall R, Comroe JH (March 1956). "A rapid plethysmographic method for measuring thoracic gas volume: a comparison with a nitrogen washout method for measuring functional residual capacity in normal subjects". The Journal of Clinical Investigation. 35 (3): 322–6. doi:10.1172/JCI103281. PMC 438814. PMID 13295396.
9. Sim YS, Lee JH, Lee WY, Suh DI, Oh YM, Yoon JS, et al. (April 2017). "Spirometry and Bronchodilator Test". Tuberculosis and Respiratory Diseases. 80 (2): 105–112. doi:10.4046/trd.2017.80.2.105. PMC 5392482. PMID 28416951.
10. Enright PL (August 2003). "The six-minute walk test". Respiratory Care. 48 (8): 783–785. PMID 12890299.
11. Swigris JJ, Wamboldt FS, Behr J, du Bois RM, King TE, Raghu G, Brown KK (February 2010). "The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference". Thorax. 65 (2): 173–177. doi:10.1136/thx.2009.113498. PMC 3144486. PMID 19996335.
12. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (July 2002). "ATS statement: guidelines for the six-minute walk test". American Journal of Respiratory and Critical Care Medicine. 166 (1): 111–117. doi:10.1164/ajrccm.166.1.at1102. PMID 12091180.
13. "Pulmonary Function Tests". www.hopkinsmedicine.org. 2019-11-19. Retrieved 2022-06-15.
14. "Pulmonary function tests: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2022-06-15.
15. "Lung Function Tests". www.lung.org. Retrieved 2022-06-15.
16. Sim YS, Lee JH, Lee WY, Suh DI, Oh YM, Yoon JS, et al. (April 2017). "Spirometry and Bronchodilator Test". Tuberculosis and Respiratory Diseases. 80 (2): 105–112. doi:10.4046/trd.2017.80.2.105. PMC 5392482. PMID 28416951.
17. "2022 GOLD Reports". Global Initiative for Chronic Obstructive Lung Disease - GOLD. Retrieved 2022-06-15.
18. Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management, and Prevention. p. 11.
19. Mohanka MR, McCarthy K, Xu M, Stoller JK (April 2012). "A survey of practices of pulmonary function interpretation in laboratories in Northeast Ohio". Chest. 141 (4): 1040–1046. doi:10.1378/chest.11-1141. PMID 21940775.
20. "About Us". Global Initiative for Chronic Obstructive Lung Disease - GOLD. Retrieved 2022-06-16.
21. Evans JA, Whitelaw WA (October 2009). "The assessment of maximal respiratory mouth pressures in adults". Respiratory Care. 54 (10): 1348–1359. PMID 19796415.