Pulmonary function testing

TLC	Total lung capacity: the volume in the lungs at maximal inflation, the sum of VC and RV.
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 VT 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 VT 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

Pulmonary function testing
Diagnostics
MeSH	D012129
OPS-301 code	1-71
MedlinePlus	003853

Pulmonary Function Testing (PFT) is a complete evaluation of the respiratory system including patient history, physical examinations, chest x-ray examinations, arterial blood gas analysis, 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 respiratory therapist.

Indications

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

• Chronic shortness of breath
• Asthma
• Chronic obstructive pulmonary disease
• Restrictive lung disease
• Preoperative testing
• Impairment or disability

Pediatric neuromuscular disorders

Neuromuscular disorders such as Duchenne muscular dystrophy are 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.^[2] 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]

Measurements

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 large 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.^[4]

Complications of spirometry

Spirometry is a safe procedure; however, there is cause for concern regarding untoward reactions. The value of the test data should be weighed against potential hazards. Some complications have been reported, including pneumothorax, increased intracranial pressure, fainting, chest pain, paroxysmal coughing, nosocomial infections, oxygen desaturation, and bronchospasm.

Lung volumes

There are four lung volumes and four lung capacities. A lung 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

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

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.

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.^[5][6][7]

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.

Techniques

Helium Dilution

The helium dilution technique for measuring lung volumes uses a closed, rebreathing circuit.^[8] 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

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.^[9]

Plethysmography

The plethysmography technique applies Boyle's law and uses measurements of volume and pressure changes to determine lung volume, assuming temperature is constant.^[10]

Interpretation of tests

Professional societies such as the American Thoracic Society/ European Respiratory Society have published guidelines regarding 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. Mohanka MR et al. recently demonstrated that only a small minority of pulmonary function laboratories followed published guidelines for spirometry, lung volumes and diffusing capacity in 2012. Ref. A survey of practices of pulmonary function interpretation in laboratories in Northeast Ohio Mohanka MR, et al. Chest. 2012;141(4):1040-1046

Significance

Changes in lung volumes and capacities are generally consistent with the pattern of impairment. TLC, FRC, and RV increase with obstructive lung diseases and decrease with restrictive impairment.

References

1. Pulmonary terms and symbols: a report of the ACCP-ATS Joint Committee on Pulmonary Nomenclature, Chest 67:583, 1975
2. Finder JD, Birnkrant D, Carl J, et al. Respiratory care of the patients with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med.2004;170 (4):456– 465
3. Sharma GD (2009). "Pulmonary function testing in neuromuscular disorders.". Pediatrics. 123 Suppl 4: S219–21. doi:10.1542/peds.2008-2952D. PMID 19420147.
4. Pulmonary Function Test in New York, Article. June 2010. Dr. Marina Gafanovich, MD - 1550 York Ave, New York NY 10028 - [phone]. NYC Pulmonary Function Test.
5. Enright PL (2003). "The six-minute walk test.". Respir Care 48 (8): 783–5. PMID 12890299.
6. Swigris JJ, Wamboldt FS, Behr J, du Bois RM, King TE, Raghu G, et al. (2010). "The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference.". Thorax 65 (2): 173–7. doi:10.1136/thx.2009.113498. PMC 3144486. PMID 19996335.
7. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (2002). "ATS statement: guidelines for the six-minute walk test.". Am J Respir Crit Care Med 166 (1): 111–7. doi:10.1164/ajrccm.166.1.at1102. PMID 12091180.
8. Hathirat S, Renzetti AD, Mitchell M: Measurement of the total lung capacity by helium dilution in a constant volume system, Am Rev Respir Dis 102:760, 1970.
9. Boren HG, Kory RC, Snyder JC: The veterans Administration-Army cooperative study of pulmonary function, II: the lung volume and its subdivisions in normal men, Am J Med 41:96, 1966.
10. Dubois AB, et al: A rapid plethysmographic method for measuring thoracic gas volume: a comparison with a nitrogen washout method for measure FRC in normal patients, J Clin Invest 35:322, 1956.