Moderator:

Prof. Rajeshwari
• Physiologic tests developed for the quantitative and
qualitative assessment of pulmonary function.

• Thereby help in assessing the presence and severity

of respiratory dysfunction.
• To evaluate Pulmonary Function in disease conditions:
- Smoking, dyspnea, cough
- COPD
- Chest wall/ spinal anomalies
- Morbid obesity

• Assess Pulmonary Function prior to Surgical procedure

in high- risk patients:
-Cardiothoracic surgery
-Major upper abdominal surgery
-Age>70 yrs for any major surgery

• Industrial set up:

-Pre employment check up
-Rehabilitation
 Bed side tests Laboratory tests

Clinical Bedside Spirometry

Pulmonary Distributio Distributio V/Q Diffusing

mechanics n of n of matching capacity
ventilation perfusion
Volumes Male Female
TV (ml) 500 500
IRV (ml) 3300 1900
ERV (ml) 1000 800
RV (ml) 1200 1100

Capacities Male Female

VC=TV+ERV+IRV 4800 3200
IC=TV+IRV 3800 2400
FRC=ERV+RV 2200 1900
TLC=TV+IRV+ERV+RV 6000 4200
✓ Breath holding test ✓ 6min walk test
✓ Snider’s match stick test ✓ Single breath count
✓ Cough test ✓ Serial counting test
✓ Lal’s stethoscope test ✓ Wright’s respirometer
✓ Chest expansion ✓ Flack test /40 mm
✓ Fall in SPO2
✓ Debono’s whistle test
✓ Wright’s peak expiratory
✓ Blowing against the flowmeter
manometer ✓ Incentive spirometry
✓ Effort tolerance
Sebrasez:Cited by Alfred Lee, 1949

• Maximal inspiration after

exhalation to RV, hold
• N = > 25 s (30-45s)
• Borderline = 25 – 15 s
• Poor CP reserve = < 15s
• Can be increased by
preoxygenation
• Respiratory force test
• MVV, timed VC

• without pursed lips, 6” distance

• Normal = 100-200 l/min

• 3”: MVV ≤50 l/min, max mid

expiratory flow <0.6l/s
• 6 " ≤ 75-100 l/min
• 9 " ≤ 100- 150 l/min

• Reliable in lower airway

obstruction
• Screening for PPC’s (atelectasis, retention of
secretions)
• Assesses ability, strength & effectiveness

• Effective cough when: VC>3×Vt,

PEFR>200l/min
• PE max < 40cmH2O impaired ability
• Productive cough
• Self propagative paroxysmal cough
• Expiratory time over trachea

• n=4-6s, no added sounds

• Prolonged in COPD

• Moderate airway obstruction

>6s with rhonchi
• After forceful inspiration at the level of the nipples
• N=2-4cm
• Restrictive disease <2cm
• Wide bore tube attached to
whistle with adjustable
leak hole
• color coded: Red, green,
yellow
• Tests respiratory muscle
strength

• PEFR up to 300 l/min or

4-5 times MBC
• Measures expiratory flow rate
• Tests respiratory muscle strength
• N=90-180mm of Hg
• For cardiopulmonary reserve
• After full inspiration subject blows as long as he/she
can into mercury manometer with force of 40mmHg
• No change in pulse rate for 1 min !normal
MV, TV, VC
Hand held/ inserted in
breathing system
Over reads at high flows
Under reads at low flows
Consistent values at
3.7-20l/min
 PEFR:

• Max inspiration—expires
forcefully
• Mean of 5 efforts
• Male: 480-700l/min
• Females: 300-500l/min
After tidal inspiration
> 6 words – normal
< 6 words – compromised
• Deep breath & counts loudly
• Respiratory reserve
• Respiratory muscle strength
• Suspect myasthenia gravis <30
• Patient’s own pace without stopping
• each stair: 6“ / step with 20 steps / flight
• > 3 flight- ↓ mortality
• < 2 flight- high risk
• cardiopulmonary reserve

• Peak VO2 max: rough estimate

• 2 flights, 20 steps/min= 16ml/kg/min
Pulse oximetry:
> 4% with exercise
respiratory flow: 600ml/s,
900 ml/s,
1200 ml/s
• Total lung capacity
• Functional residual capacity
• Vital capacity
• Residual volume
• VC: spirometry
• RV: gas dilution/ plethysmography

• Mild <80% predicted

• Moderate <60%
• Severe < 40%
• Highly reproducible
• Day to day variation<5%

• Measured:
1. Inert gas dilution:N2 open circuit/ He closed circuit
2. Body plethysmography
Measures:
1.Raw
2.Lung compliance
3.All volumes and
capacities
Increased FRC: Increased RV:
• Hyperinflation Hyperinflation even
• Does not always signify after maximal effort
disease Causes may be
• ↑ FRC: slower anesthetic
reversible/ irreversible
induction Significance

RV/TLC ratio:
N=20-35%
Old age
Absolute ↑: asthma
Relative ↑: restrictive lung disease
• Largest volume measured after subject inspires to
TLC and expires to RV
• Lower in supine than in sitting position
• Varies with height/ age
• Greatest at 25-30yrs
• ↓ 200ml/ decade (TLC ↓100ml/decade)
 Chronic Asthma Emphysema Restrictive
bronchitis disease

TLC N N/↑ ↑ ↓

FRC ↑ ↑ ↑ N/↓

RV ↑ ↑ ↑ N/↓

VC ↓ ↓ N ↓↓

<80% or >120%= abnormal

• Clinical spirometry: JOHN HUTCHISON
• All volumes & capacities except FRC, RV, TLC

Forced vital capacity (FVC)

Peak expiratory flow rate (PEFR)
Forced expiratory volume in 1 sec (FEV1)
Timed FEV/FVC
Forced expiratory flow (FEF)
Forced inspiratory flow (FIF)
Maximum voluntary ventilation (MVV)
Respiratory muscle strength
• VC maneuver done
forcefully and rapidly
• Exhaled volume v/s
time
• Normal: FVC=VC
• 3 readings, 4 sec
apart, not interrupted
by coughing, glottic
closure, mechanical
obstruction
• Expiratory flow
averaged over pre-
selected segment
• Assessing the dynamic
airway obstruction
• 3 readings, averaged
• Depends on:
1. Caliber of airway
2. Patient’s effort
3. VC

• 5 times, average of last 3 taken

• Personal best taken
• Males: 450-700l/min
• Females: 300-500l/min
• <200: impaired cough efficiency, ↑ post op
complications
Uses:
• Diagnosis of asthma: 3-4 times/daily, >15% variability
• Assess reversibility: pre and post broncho-dilation

therapy, ↑ 10-15%
• Exercise induced asthma: at rest, 2min intervals in 6

min exercise, ↓ >15%

• Assess severity
• Circadian variation (↑ nocturnal)
• Monitor response to therapy, disease course follow up
• % of FVC exhaled in 1st sec during FEV maneuver
• N=3-4.5l/sec
• Mild: 1.5-2l/sec
• Handicapped: <1 l/sec
• Disability: 0.8 l/sec
• Severe emphysema: 0.5l/sec

• ↓ after 25-30yrs, 73ml/yr

• ↓ COAD, airway diameter ≤6mm
• Asthma: ↑of 200ml/sec or >15%: reversibility
 Obstructive Restrictive

FVC N ↓

FEV1 ↓ ↓

FEV1 /FVC <70% >70%

Measurd over 1l of initial
part of spirogram
Begins at 200ml to permit
attainment of PEFR
N>500l/min
<200l/min: ↓ cough
efficiency
Larger airways, not small &
medium
• Measured over mid half
of VC
• Sensitive indicator of
early airway dysfunction
• N=4.5-5l/sec
• Variable index, depends
on FVC & changes in exp
time with varying
obstruction
• Assess at low lung
volumes
• Sensitive indicator of
small airway dysfunction
•FVC ↑in B, but flow over its
midportion (FEF25%–75% ) is
↓unless adjusted to the same
volume.

•Results from ↑FVC due to

bronchodilation.

•If FEF25%–75% measured over

same volume segment as in A, the
value increases.
➢Measured using forced
spirogram, flow volume loop

➢Effort dependent

➢↓ in MG
• Max volume breathed in 1 min by voluntary effort
• Estimate of peak ventilation to meet physiological demands
• Breathe as fast & hard as possible for 12 sec—1min

• F=40-70/min, TV=50% of VC
• N=150-175l/min

• COAD: ↓ out of proportion to ↓in VC

• Restrictive: N despite ↓in VC

• Correlates well with FEV1

• MVV= FEV1×35
• Generating pressures against
occluded airway during max
forced inspiratory & expiratory
effort

• Pimax: at RV
N= -125cm H2O
>-25cm H2O: extubation
criteria

• PEmax: at TLC
N= +200cm H2O
<40cm H2O: post op
hypercapnic respiratory failure
• Forced expiratory maneuver

• Flow rate peaks in early

expiration, then decreases

• Lower lung volumes, effort

independent as airflow
restricted by airway
resistance only
Fixed Variable extrathoracic Variable intrathoracic

Tracheal stenosis Thyroid gland enlargement Tracheal tumor

Both plateau effect Inspiratory plateau Expiratory plateau

Mid VC ratio=1 Mid VC ratio>2 Mid VC ratio<0.3

• ΔV/ ΔP
• 1/CT=1/CL+1/CCW
• CL =CCW= 0.2L/cmH2O
• CT=0.1L/cmH2O

• Swallow latex balloon in

esophagus, connected to
pressure transducer
• ΔV by spirometer
• ΔP of esophagus = intrapleural
pressure
• PR= Raw+ Tissue R Gaw=1/ Raw
• Pneumotachygraph, PP with Varies linearly with LV
latex balloon, n=0.5-2cmH2O Specific conductance=Gaw/
• PR= flow rate/ Ppl LV
• varies non lineraly with LV Highly reproducible, identify
small airway changes
 Physiologic Variables

Disease PEmax Raw PL

Neuromuscular weakness ↓ N N

Emphysema N N ↓

Asthma, bronchitis N ↑ N

Peripheral airway disease N N N

• Frequency dependance of compliance
• Residual volume measurement
• FEF25-75
• FEF75-85
• FVC/Forced expiratory time
• Flow volume loops with different gas densities (>vol
of isoflow > is obstruction, best indicator)
• Single breath N2 washout test
• Multiple breath N2 washout test
• Radio isotope technique
• 4 phases
• Phase 3 : n <2.5% variation

• Closing volume: lung volume at

which the dependent smaller
airways cease to contribute to
expired gas. N= 15-20% VC

• Closing capacity: CV + RV, % TLC

• FRC & CC: ↓ FRC/↑ CC: atelectatic
areas.
Expired N2 conc. plotted on
logarithmic scale
against cumulative expired
volume during pure oxygen
breathing.
➢Radioactive Xe 133

➢Measuring radioactivity
over lung region

➢Quatitative measure of
distribution
1. Radioisotope technique: sensitive, qualitative
2. Pulmonary angiography

Vd/Vt ratio: higher-more mismatch

Modified fick equation for shunt flow to total blood

flow: Qs/Qt=
[PAO2-PaO2]0.003/[PAO2-PaO2]0.003+5
• Depends on: ➢Complex method
➢ Character of alveolar capillary
membrane ➢CO diffuses 0-8 times as rapidly
➢ Effective surface area for gas as O2, 200 times > affinity for Hb.
exchange
➢Normal: 30ml/min/mmHg
➢ Volume of blood in alveolar
capillaries ➢DLCO= CO/ PAco- Pcco
➢ Cardiac output
➢ Rate of combination of gas with ➢Affected by alveolar volume
blood
➢Krogh’s constant= DLCO/ VA

➢Methods: steady state method,

single breath technique
Lung pathology: Dlco Dlco/VA
Pneumonectomy ↓ N( proportinal to TLC↓)
Emphysema ↓ ↓
Pulmonary embolism
Anemia
Polycythemia ↑ ↑
LVF
L-R shunt
COAD N N

DLO2 = DLCO × 1.23

What Dr Rajeshwari said: