DR.V.NANDAGOPAL.MD(TB &RESP.

DIS)
CONSULTANT PULMONOLOGIST
ASTHMA,ALLERGY RESPIRATORY CARE
G.K.N.M.HOSPITAL, COIMBATORE
 Doctors make diagnoses,
not spirometers.
First, look at all the curves.
Two basic patterns of abnormality:

Obstruction and Restriction

Obstruction = narrow airways
Restriction = small lungs
Flow-volume loop pattern recognition

Normal
Low FEV1/FVC = Obstruction

Low FVC = Restriction

FEV1 %predicted to grade severity

Asthma and COPD reduce airway diameter and
reduce the patients ability to blow out quickly.

Various causes of obstruction

Which parameter is used to
detect airway obstruction?

A) FEV1
B) FVC
C) FEF 25-75%
D) FEV1/FVC
 After looking at the curves,
look at the numbers.

% Predicted
FEV1

% Predicted
FVC

FEV1 / FVC

A low FEV1/FVC confirms airway obstruction.

 Spirometry interpretation flow chart

FEV1 / FVC%

Low Normal

FVC
FVC

Normal Low Normal Low

Obstruction Mixed Normal Restriction

Which number is used to
determine
the severity [degree] of
obstruction ?
A) FVC
B) FEV1
C) FEV1/FVC
D) FEF25-75%
Staging asthma severity

Severity FEV1
Intermittent Normal

Mild > 80%

Moderate 60-80%

Severe < 60%

 Staging COPD Severity
using the GOLD Guidelines

FEV1 post
BD
At risk smoker Normal

Mild 80%
Moderate 50-80%
Severe 30-50%
Very Severe 30%
 Interpretation pitfalls

Poor patient effort or compliance

(look at the curves)
Poor coaching technique
Instrument errors
A 25 year old male, non-smoker with occasional dyspnea.

10
FEV1
=
3.3 L
Pattern ?
FVC 4.0 L
PEF
Exp. Flow(L.s1)

5
A) Normal
FEV1 B) Obstruction
0

0
TLC
2 4
C) Restriction
Volume (L)
5 D) Mixed
Insp. Flow(L.s1)

MIFV
A 55 year old female smoker with dyspnea climbing stairs

FEV1
=
2.4 L
Pattern ?
FVC 3.7 L

A) Normal
B) Obstruction
TLC RV C) Restriction
0 2 4
Volume (L) D) Mixed
A 66 year old man with a history of COPD admitted for
an exacerbation. How severe is his airway obstruction?

10 FEV1 0.8 L
=
FVC 2.2 L

A) Mild
5

B) Moderate
0 C) Severe
RV

D) Very severe
Volume (L)
5
 A 50 year old female had admission for organophosphorus
poisoning and had prolonged ventilation. What is the most
likely cause of this flow-volume loop pattern?

FEV1 3.2 L
=
FVC 3.8 L
5
Exp. Flow(L.s1)

A) Asthma
B) COPD
TLC
0
0 2 4
C) Narrow trachea
Insp. Flow(L.s1)

Volume (L)
D) Pulmonary fibrosis
Types of Upper Airway Obstruction (UAO)

Fixed UAO VI-UAO VE-UAO

 FEV1 2.7 L
=
5
FVC 3.4 L What is the UAO pattern ?

A) Fixed intrathoracic
FEV1

TLC RV
B) Variable intrathoracic
0
0 2 4
C) Fixed extrathoracic
D) Variable extrathoracic
 FEV1
=
2.7 L
3.4 L
A) Vocal cord paralysis
FVC
5
B) Tracheal stenosis

FEV1
C) A large goiter
TLC RV D) Cancer at the carina
0
0 2 4
 A) Parkinsons
B) Vocalization
C) Coughing
D) Sleep apnea
0 3
 Ms.
Anisha

A 25 year old non atopic female H/o chest pain and

dry cough with occasional mucoid expectoration
since 4years. Cough was more during early morning
hours and especially on laughing or on exercise. Has
had two episodes of breathlessness.
Symptoms increased over the last 2mnths. She
confessed that she had not slept soundly for 4 days
due to cough.
H/o recurrent upper respiratory tract infections
since1yr
O/E: Bilateral rhonchi
CXR: Clear
A) Gastro-esophageal reflux
B) Post-nasal drainage
C) Bronchiectasis
D) Asthma
Green dots are predicted normal values.
A) COPD
B) Upper airway obstruction
C) Bronchiectasis
D) Asthma
A 25 year old non atopic female H/o chest
pain and dry cough with occasional mucoid
expectoration since 4years. Cough was
more during early morning hours and
especiallyOur diagnosis:
on laughing or on exercise. Has
had twoBronchial Asthma:
episodes of breathlessness.
Symptoms increased over the last 2mnths.
GINA grade:
She confessed Severe
that she had not slept
soundly for 4 days due to cough.
H/o recurrent upper respiratory tract
infections since1yr
O/E: Bilateral rhonchi
CXR: Clear
Mike Mellow
Pattern ?

A) Upper airway obstruction

B) Severe intrathoracic obstruction
C) Poor expiratory efforts
D) Severe restriction of volumes
Mike Mello
A) COPD
B) Upper airway obstruction
C) Pulmonary fibrosis
D) Asthma

Mr. DMello
 Spirometric Diagnosis:

Severe Obstructive Airways Disease with

poor BDR
or
Mixed obstructive plus restrictive defect.
 Diagnosis:

Chronic Obstructive Pulmonary

Disease
GOLD Grade: Very Severe
0.30

52%

Mike Mello
35
 Airway obstruction commonly causes
hyperinflation, lowering the FVC.

Over
9 Distention
8 Small
Hyper
Airway Inflation
7 Closure
LC
6 T
liters
5

4 FRC
3
2 RV
1

Normal Mild Moderate Severe

 Mike Mellos post BD FEV1 = 0.5 liters, 17% predicted
Very severe COPD, GOLD stage IV

COPD Management per GOLD guidelines

37
Mr. Roy:
Case Study 3:
Mr. Roy

Acceptable?
Pattern ?

A) Severe obstruction
B) Severe restriction
C) Mixed abnormality
D) Poor effort
Rob Roy
Mr. Roy
 Mr. Roy:

Diagnosis: Restrictive Lung

Disease
 Grading severity of RLD

FVC range as %
of predicted Severity grade
values

60 80 Mild
45 60 Moderate
< 45 Severe
Suniel Sakahram
Case Study 4: Mr.
Sakharam
 Blue = post BD

Pattern ?

A) Severe obstruction, volume response

B) Severe obstruction, no BD response
C) Severe restriction
D) Poor efforts
Mr.
Sakhara
m
Mr.
Sakhara
m
 Mr.
Sakhara
m

Is this Reversible Airways

Disease?
 Mr.
Sakhara
m

Spirometric Diagnosis:

Restrictive Lung Disease

Poor Bronchodilator
Reversibility
 Diagnosis:

Chronic Bronchial Asthma

Poor Bronchodilator
Reversibility

Auscultation revealed bilateral

rhonchi
Important to note

POORLY CONTROLLED
ASTHMA CAN LEAD
TO FIXED AIRWAY
OBSTRUCTION
LEADING TO
DIFFICULT TO TREAT
ASTHMA!
Poorly Controlled Asthma

Severe airway obstruction

Mixed pattern on spirometry
Low FVC due to hyperinflation
Little response to salbutamol
Sometimes a volume response
FVC increases but not FEV1
Airway edema does not resolve quickly
 Role of Spirometry in Smoking Cessation

You notice yellow fingers and ask Mr. Sakharam why.

He admits to smoking since teenage years.
You say, smoking makes your asthma very difficult to
treat.
He says, Ive tried to stop many times.
You offer bupropion and nicotine replacement therapy.
Describe the benefit of smoking cessation to each patient.
 Pre-operative Evaluation
Pulmonary Resection Surgery
A 45-year old
Test Pre BD Pred
chronic smoker
presented with d ppo
cough and Befo
re
After

haemoptysis since
FVC(L) 4 3 3 2.5
6 months.
FVC% 75 75
O/E--- grade 3
clubbing and signs FEV1(L 3 2.5 2.5 2
of right upper lobe )
obstructive FEV1/FV 75 75
collapse. C

CXR showed right

upper collapse
with bronchus
cut off sign.
 Pre-operative Risk Assessment For
Other Surgery
FEV1

75%

LOW
50%

MODERA
TE
25%
HIG
H
25 50 75% FVC
 Summary

1. Examine the curves for test

quality.
2. Recognize the obstruction
pattern.
3. Check the FEV1/FVC for
obstruction.
4. For severity, check FEV1 %
predicted.
Thank- you