Visit us at www drsarma in Dr R

Visit us at www. drsarma. in Dr. R. V. S. N. Sarma. , M. D. , M. Sc. , Consultant Physician & Chest Specialist E mail: sarma. rvsn@gmail. com 3760 9226 or 2766 0593 93805 21221 or 98940 60593 www. drsarma. in

Pulmonary Function Tests Ventilatory Function – Spirometry Clinical Applications www. drsarma. in

LUNG FUNCTION TESTS l Tests of Ventilation l Tests of Diffusion l Tests of Perfusion l Tests for V-P Mismatch www. drsarma. in

LUNG FUNCTION TESTS l Tests of Ventilation l Tests of Diffusion l Tests of Perfusion l Tests for V-P Mismatch www. drsarma. in

Function of Ventilation l Air Exit – Airways, Bronchomotor tone, Secretions, Thoracic muscles etc l Air Entry – Expansion of lungs – Functioning lung volume, its elastic nature, Lung compliance l ‘Air Out’ Problem – Obstructive Diseases l ‘Air In’ problem – Restrictive Diseases l Both Air Out and In - Combined www. drsarma. in

Spirometry Objectives Ø To detect Obstructive Airway Diseases Ø To quantify the severity of obstruction. Ø To assess response to IBD. Ø To identify Restrictive Lung Diseases. Ø To identify flow-volume loop patterns Ø To understand the clinical relevance. www. drsarma. in

PEAK FLOW METER Diagnosis of ASTHMA or COPD can be confirmed by demonstrating the presence of airway obstruction using Spirometry. www. drsarma. in

PEFR - Pros and Cons l Advantages l With in 1 to 2 minutes, l Inexpensive (meter costs less than Rs. 1000) l Simple, useful for frequent follow up use l Disadvantages l Very much effort dependent l Insensitive to small changes l Small airways cannot be assessed l Large inter & intra subject variation; ↓accurate www. drsarma. in

SPIROMETRY www. drsarma. in

SPIROMETRY www. drsarma. in

SPIROMETRY www. drsarma. in

SPIROMETRY www. drsarma. in

Spirometry - Pros and Cons l Advantages l Evaluates smaller as well as larger airways l Relatively easy to use and maintain l Reversibility can be tested with IBD and steroids l Diagnostic as well as management assessments l Disadvantages l Costs about 50, 000 + computer and printer l Takes time to perform – 10 to 15 minutes l Requires training – at least one day course www. drsarma. in

Spirometry Maneuver In single breath test l A few normal tidal respirations l Then deeeeep inspiration l Momentary breath holding l Very forced and fast expiration l As hard and as fast as he/she can blow out l Then deep, quick and full inspiration l Repeat at least 3 times – take the best www. drsarma. in

Reproducibility of Spirometry l Adequate explanation to the patient l Demonstrating the steps one by one l Encouraging the patient to give best effort l Taking at least 3 and usually 5 attempts l Selecting the best effort l Cough and severe dyspnoea may interfere l Not like ECG – Results depend on effort www. drsarma. in

Spirometry Results l FVC l FEV 1/FVC l PEFR l FET www. drsarma. in Forced Vital Capacity Forced Expiratory Volume in the first second Ratio of the above two Peak Expiratory Flow Rate Forced Expiratory Time

Normal Flow-Volume-Time Test Values www. drsarma. in

Spirometry Results l FVC l FEV 1/FVC l PEFR l FET www. drsarma. in Forced Vital Capacity Forced Expiratory Volume in the first second Ratio of the above two Peak Expiratory Flow Rate Forced Expiratory Time

Spirometry Normal Values There are no fixed ‘Normal’ values 2. Dependent on age, sex, height, weight, ethnicity 3. Observed value expressed as % of predicted value 1. l l l FVC FEV 1/FVC PEFR FET www. drsarma. in Normal if > 80% of predicted At least 75% Normal if > 80% of predicted Less than 4 seconds

FEV 1 NORMAL The Four Square Game FEV 1 < 80% of Pd. 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 NORMAL The Four Square Game Normal Lungs FEV 1÷FCV is N FEV 1 < 80% of Pd. 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 NORMAL The Four Square Game FEV 1 < 80% of Pd. 80% Obstructive Disease FEV 1÷FCV is Low 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

Restrictive Disease FEV 1÷FCV is High 80% FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game 80% Combined Obs+Res FEV 1÷FCV is N or L 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game Restrictive Disease FEV 1÷FCV is High Normal Lungs FEV 1÷FCV is N 80% Combined Obs+Res Obstructive Disease FEV 1÷FCV is N or L FEV ÷FCV is Low 1 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game Air Entry Problem Lungs ↓ expansion Normal Air Entry & Exit 80% Both Air Entry & Air Exit Problem Airways choked 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game Restrictive Disease FEV 1÷FCV is High Normal Lungs FEV 1÷FCV is N 80% Combined Obs+Res Obstructive Disease FEV 1÷FCV is N or L FEV 1÷FCV is Low 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

Millers Prediction Quadrants FEV 1 < 80% of Pd. FEV 1 NORMAL 100% Air Entry is reduced Air In and Out N Restrictive Disease 90% Normal Lungs FEV 1÷FCV is High FEV 1÷FCV is N 60% 70% 80% 90% 100% Both Air In & Out ↓↓ Air Exit is chocked Combined Obs+Res Obstructive Disease 70% FEV 1÷FCV is N or L FEV 1÷FCV is Low FVC < 80% Pred. www. drsarma. in 60% FVC NORMAL

Algorithm for Diagnosis FVC > 80% FVC < 80% FEV 1 > 80% FEV 1 < 80% Normal PFT Obstructive Restrictive Combined Extra-pulmonary Pulmonary IBD Reversible www. drsarma. in Irreversible

Normal Airways and Lungs FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in l FVC l FEV 1÷FCV > 80% > 75% l PEFR l FET > 80% <4 sec Air Entry l Air Exit Normal l

Normal Airways - PFT www. drsarma. in

Normal PFT and CXR www. drsarma. in

Obstructive Airways Disease l Bronchial Asthma – Reversible Airway obs. l Chronic bronchitis – Irreversible with IBD l Emphysema – Irreversible with IBD l Bronchiectasis – Airway rigidity l Cystic Fibrosis l Allergic bronchopulmonary Aspergillosis l Bronchiolitis www. drsarma. in

Obstructive Airways Disease FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in l FVC l FEV 1÷FCV > 80% < 75% PEFR l FET < 80% >4 sec l Air Entry l Air Exit l Normal Problem

Obstructive Airways Disease - PFT FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in

Obstructive V/s Normal www. drsarma. in

Obstructive Airways Mild Bronchial Asthma www. drsarma. in

Reversible Obstruction (IBD) Bronchial Asthma www. drsarma. in

Bronchiectasis (Obstructive) BRONCHOGRAM - BIL www. drsarma. in UNILATERAL

Obstructive Airways Severe Emphysema www. drsarma. in

Obstructive Airways Severe -IBD Emphysema www. drsarma. in

Obstructive Lung Diseases ABPA www. drsarma. in CYSTIC FIBROSIS

Upper Airway Obstruction l l Truncation of flow loop Expiratory – Intra Thoracic Inspiratory –Extra Thoracic Both – Fixed Obstruction l l Tumour Tracheal stenosis Tracheal FB Vocal Chord Dysfunction www. drsarma. in

Restrictive Lung Diseases l Sarcoidosis l Tuberculosis – (Fibrocaseous) l Interstitial Lung Disease - ILD l Idiopathic pulmonary fibrosis - IPF l Pneumoconiosis l Drug- or radiation-induced lung disease l Pneumonectomy www. drsarma. in

Extrinsic Restrictive Diseases l Kyphosis, Scoliosis l Ankylosing Spondylitis l Massive Pleural effusion l Pregnancy, Obesity, Ascites l Rib fractures l Neuromuscular disorders www. drsarma. in

Restrictive Lung Disease FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in l FVC l FEV 1÷FCV < 80% > 75% PEFR l FET > 80% <4 sec l Air Entry l Air Exit l Problem Normal

Restrictive Lung Disease - PFT ILD or IPF FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in

Restrictive V/s Normal ILD or IPF www. drsarma. in

Restrictive Lung Disease - ILD or IPF www. drsarma. in

Restrictive Lung Disease - ILD HEPATIOD APPEARANCE www. drsarma. in

Restrictive Lung Disease - ILD RETICULAR PERIPHERIES www. drsarma. in

Restrictive Lung Disease - ILD HRCT Chest www. drsarma. in X-RAY CHEST - ILD

Restrictive Lung Diseases SARCOIDOSIS www. drsarma. in RETICULO-NODULAR

Combined Obstructive + Restrictive FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in l FVC l FEV 1÷FCV < 80% < 75% PEFR l FET < 80% >4 sec l Air Entry l Air Exit l Problem

Combined Obstructive + Restrictive FEV 1 is LOW FVC is Normal FEV 1 ÷ FVC is < 75% www. drsarma. in

Combined Obstructive + Restrictive KOCHS + EMPHYSEMA www. drsarma. in

Other Patterns FIXED OBSTRUCTION www. drsarma. in

Other Patterns COUGH EXTRA THORACIC www. drsarma. in

Case 1 Test Pred. Meas. % FVC 5. 5 L 4. 5 L 82% FEV 1 4. 9 L 3. 0 L 61% Ratio 89% 66% - Man, aged 28, 172 cm, 71 kg Non smoker, Cough 3 M www. drsarma. in

Case 1 Test Pred. Meas. % FVC 5. 5 L 4. 5 L 82% FEV 1 4. 9 L 3. 0 L 61% Ratio 89% 66% - Man, aged 28, 172 cm, 71 kg Non smoker, Cough 3 M Dx : Bron Asthma - Rev www. drsarma. in IBD Good Response

Case 2 Test Pred. Meas. % FVC 3. 9 L 2. 6 L 66% FEV 1 3. 1 L 2. 4 L 78% Ratio 79% 92% - Woman, 48 y, 155 cm, 47 kg Non smoker, Dysp. , CP www. drsarma. in

Case 2 Test Pred. Meas. % FVC 3. 9 L 2. 6 L 66% FEV 1 3. 1 L 2. 4 L 78% Ratio 79% 92% - Woman, 48 y, 155 cm, 47 kg Non smoker, Dysp. , CP Diagnosis : # Ribs 5, 6, 7, 8 www. drsarma. in

Case 3 Test Pred. Meas. % FVC 6. 0 L 5. 0 L 83% FEV 1 4. 8 L 4. 1 L 85% Ratio 80% 82% - Man 35, 175 cm, 75 kg, MC Non smoker, Clinical N www. drsarma. in

Case 3 Test Pred. Meas. % FVC 6. 0 L 5. 0 L 83% FEV 1 4. 8 L 4. 1 L 85% Ratio 80% 82% - Man 35, 175 cm, 75 kg, MC Non smoker, Clinical N Diagnosis : Normal PFT www. drsarma. in

Case 4 Test Pred. Meas. % FVC 1. 9 L 0. 7 L 36% FEV 1 1. 6 L 0. 4 L 25% Ratio 84% 57% - Child, 8 y, 128 cm, 19 kg Stridor, Dysp G 3, BS Decr. www. drsarma. in

Case 4 Test Pred. Meas. % FVC 1. 9 L 0. 7 L 36% FEV 1 1. 6 L 0. 4 L 25% Ratio 84% 57% - Child, 8 y, 128 cm, 19 kg Stridor, Dysp G 3, BS Decr. FB in the UAW www. drsarma. in

Case 5 Test Pred. Meas. % FVC 3. 5 L 1. 8 L 51% FEV 1 2. 8 L 1. 2 L 43% Ratio 80% 66% - Woman, 29 y, 160 cm, 41 kg Had ATT, Dysp G 3, Wheeze www. drsarma. in

Case 5 Test Pred. Meas. % FVC 3. 5 L 1. 8 L 51% FEV 1 2. 8 L 1. 2 L 43% Ratio 80% 66% - Woman, 29 y, 160 cm, 41 kg Had ATT, Dysp G 3, Wheeze Diagnosis : TB + ABPA www. drsarma. in

Case 6 Test Pred. Meas. % FVC 4. 5 L 3. 7 L 82% FEV 1 3. 6 L 1. 8 L 50% Ratio 80% 49% - Man, aged 58, 165 cm, 51 kg Smoker 16 yr, Severe Dysp. www. drsarma. in

Case 6 Test Pred. Meas. % FVC 4. 5 L 3. 7 L 82% FEV 1 3. 6 L 1. 8 L 50% Ratio 80% 49% - Man, aged 68, 165 cm, 51 kg Smoker 16 yr, Severe Dysp. DX : COPD- Irreversible www. drsarma. in IBD NO Response

FEV 1 < 80% of Pd. FEV 1 NORMAL The Four Square Game Restrictive Disease FEV 1÷FCV is High Normal Lungs FEV 1÷FCV is N 80% Combined Obs+Res Obstructive Disease FEV 1÷FCV is N or L FEV 1÷FCV is Low 80% FVC < 80% Pred. www. drsarma. in FVC NORMAL

Millers Prediction Quadrants FEV 1 < 80% of Pd. FEV 1 NORMAL 100% Air Entry is reduced Air In and Out N Restrictive Disease 90% Normal Lungs FEV 1÷FCV is High FEV 1÷FCV is N 60% 70% 80% 90% 100% Both Air In & Out ↓↓ Air Exit is chocked Combined Obs+Res Obstructive Disease 70% FEV 1÷FCV is N or L FEV 1÷FCV is Low FVC < 80% Pred. www. drsarma. in 60% FVC NORMAL

Take Home Points l All that wheezes is not Asthma only l All Dyspnoea does not wheeze l Do not over simplify dyspnoea to Deriphyllin l Etiology of Dyspnoea needs elucidation l Spirometry tests but Ventilation function only l Need to test diffusion, Perfusion functions l Cardiac, Hematologic and other causes www. drsarma. in

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