Spirometry (Pulmonary Function Tests) By: A. H. Mehrparvar, M.D.
Usage of Pulmonary Function Tests in Clinic Except Spirometry Diffusion Capacity
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Transcript of Usage of Pulmonary Function Tests in Clinic Except Spirometry Diffusion Capacity
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Usage of Pulmonary Function Usage of Pulmonary Function Tests in Clinic Except Tests in Clinic Except
Spirometry Diffusion CapacitySpirometry Diffusion Capacity
Prof.Dr.Birsen MUTLUProf.Dr.Birsen MUTLU
I.U.Cerrahpasa Medical FacultyI.U.Cerrahpasa Medical Faculty Department of Pulmonary DiseasesDepartment of Pulmonary Diseases
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Pulmonary Function Tests Application FieldPulmonary Function Tests Application Field
1-Diagnosis and treatment of Lung and 1-Diagnosis and treatment of Lung and Heart diseases Heart diseases
2-Preoperative evaluation2-Preoperative evaluation3-Evaluation of disability3-Evaluation of disability4-Epidemiologic studies for the 4-Epidemiologic studies for the
evaluation of industrial diseasesevaluation of industrial diseases5-Simple determination of disease 5-Simple determination of disease
incidence in a given population incidence in a given population
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-Alveols -Alveols
-Airways (Ventilation)-Airways (Ventilation)
-Capillary network (perfusion)-Capillary network (perfusion)
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-Ventilation-Ventilation
-Distribution-Distribution
-Diffusion-Diffusion
-Perfusion-Perfusion
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Pulmonary Function TestsPulmonary Function Tests
A- Airway functionA- Airway function 1.Simple spirometry1.Simple spirometry Vital capacity(VC),expiratory reserve volume Vital capacity(VC),expiratory reserve volume (ERV), (ERV),
inspiratory capacity (IC)inspiratory capacity (IC)
2.Forced vital capacity maneuver2.Forced vital capacity maneuver a-FVC,FEV1,FEF,PEFa-FVC,FEV1,FEF,PEF (1)Prebronchodilator and postbronchodilator(1)Prebronchodilator and postbronchodilator (2)Prebronchochallenge and (2)Prebronchochallenge and
postbronchochallengepostbronchochallenge
b-MEFV curves,Vmaxb-MEFV curves,Vmaxxx
(1)Prebronchodilator and Postbronchodilator(1)Prebronchodilator and Postbronchodilator (2)Prebronchochallenge and (2)Prebronchochallenge and
postbronchochallengepostbronchochallenge
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3.Maximal voluntary ventilation3.Maximal voluntary ventilation (MVV)(MVV)
4.Maximal inspiratory/expiratory 4.Maximal inspiratory/expiratory pressures (MIP/MEP)pressures (MIP/MEP)
5.Airway resistance (Raw) and 5.Airway resistance (Raw) and Compliance (C)Compliance (C)
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B-Lung volumes and ventilationB-Lung volumes and ventilation 1.Functional residual capacity (FRC)1.Functional residual capacity (FRC) a.Open-circuit (N2 washout)a.Open-circuit (N2 washout) b.Closed-circuit/rebreathing ([He dilution)b.Closed-circuit/rebreathing ([He dilution) c.Thoracic gas volume (Vc.Thoracic gas volume (VTGTG)) 2.Total lung capacity (TLC),residual 2.Total lung capacity (TLC),residual
volume (RV),RV/TLC ratiovolume (RV),RV/TLC ratio 3.Minute ventilation,alveolar ventilation and 3.Minute ventilation,alveolar ventilation and
dead space dead space 4.Distribution of ventilation4.Distribution of ventilation a.Multiple-breath N2a.Multiple-breath N2 b.He equilibrationb.He equilibration c.Single-breath techniquesc.Single-breath techniques
Pulmonary Function TestsPulmonary Function Tests
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Pulmonary Function TestsPulmonary Function Tests
C- Diffusion capacity testsC- Diffusion capacity tests
1. Single-breath(breath holding)1. Single-breath(breath holding)
2. Steady state2. Steady state
3. Other techniques3. Other techniques
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D-Blood gases and gas exchange testsD-Blood gases and gas exchange tests
1.Blood gas analysis 1.Blood gas analysis
2. Pulse oximetry2. Pulse oximetry
3. Capnography3. Capnography
Pulmonary Function TestsPulmonary Function Tests
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E- Cardiopulmonary exercise testsE- Cardiopulmonary exercise tests
1. Simple noninvasive tests1. Simple noninvasive tests
2. Tests with exhaled gas analysis2. Tests with exhaled gas analysis
3. Tests with blood gas analysis3. Tests with blood gas analysis F- F- Metabolic measurementsMetabolic measurements
Pulmonary Function TestsPulmonary Function Tests
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DIFFUSIONDIFFUSION
This is an electrochemical event This is an electrochemical event between gas and liquid. Occurs due between gas and liquid. Occurs due to the partial pressure difference of to the partial pressure difference of the gases.the gases.
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DIFFUSION CAPACITYDIFFUSION CAPACITY
Amount of gas (mL) passed through Amount of gas (mL) passed through the capillary membrane in a given the capillary membrane in a given time(1min) and in a given pressure time(1min) and in a given pressure difference (1mmHg) difference (1mmHg) (mL/min/mmHg)(mL/min/mmHg)
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DIFFUSION VELOCITYDIFFUSION VELOCITY
V=A.k.α.(PV=A.k.α.(P11--PP22))
hhV=Diffusion velocity within a given timeV=Diffusion velocity within a given timeA=Diffusion surface areaA=Diffusion surface areak=diffusion constantk=diffusion constantα=gas solubilityα=gas solubilityPP1-1-PP22= Partial pressure difference of two = Partial pressure difference of two
environment that the diffusion takes environment that the diffusion takes place in.place in.
h=membrane thicknessh=membrane thickness
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Factors that effect diffusion velocityFactors that effect diffusion velocity
-k (diffusion constant)-k (diffusion constant)-Α (solubility)-Α (solubility)-Viscosity of diffusion milieu-Viscosity of diffusion milieu
Air diffusion velocity>water diffusionAir diffusion velocity>water diffusion velocityvelocity
**Tissue diffusion velocity Tissue diffusion velocity == fluid diffusion fluid diffusion velocityvelocity
**Exclusion: Exclusion:
Erythrocyte hb concentration viscosity Erythrocyte hb concentration viscosity diffusion diffusion velocityvelocity
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-CO is the standart gas that used in -CO is the standart gas that used in diffusion measurementsdiffusion measurements
-It has high Hgb. affinity-It has high Hgb. affinity
-The only factor that limits CO diffusion is -The only factor that limits CO diffusion is alveolocapillary membranealveolocapillary membrane
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ERS (1993) TERS (1993) TLLCO:Transfer factorCO:Transfer factor
ATS (1995) DATS (1995) DLLCO:Diffusion capacityCO:Diffusion capacity
DDLLCO=mL/dak/mmHgCO=mL/dak/mmHg
TTLLCO=mmoL/dak/kPaCO=mmoL/dak/kPa
DDLLCO/TCO/TLLCO =3:1CO =3:1
DDLLCO x O.33=TLCOCO x O.33=TLCO
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Diffusion ventilation ratioDiffusion ventilation ratio
ERS TERS TLLCO/VA (=KCO)Transfer CO/VA (=KCO)Transfer coefficient coefficient
ATS DATS DLLCO/VACO/VA
(mL/dak/mmHg)(mL/dak/mmHg)
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Methods used in diffusion Methods used in diffusion measurementmeasurement
1-Single-breath holding1-Single-breath holding
2-Single expiration2-Single expiration
3-Rebreathing3-Rebreathing
4-Steady state4-Steady state
5-Riley-Lilienthal5-Riley-Lilienthal
6-V6-VAA/Q/Q
7-Single breath oxygen holding7-Single breath oxygen holding
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Resting DResting DLLCO:25 mLCO/min/mmHgCO:25 mLCO/min/mmHg
%81-140 (predicted)=>normal%81-140 (predicted)=>normal
%61-80 (predicted)=>mild decrease%61-80 (predicted)=>mild decrease
%41-60 (predicted)=>moderate%41-60 (predicted)=>moderate
<%40 (predected)=>significantly <%40 (predected)=>significantly decreased decreased
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Factors that effect DFactors that effect DLLCO CO measurementmeasurement
1-Age,height,body surface area1-Age,height,body surface area
2-Cigarette smoking2-Cigarette smoking
3-Hemoglobin level3-Hemoglobin level
4-Body position and exercise4-Body position and exercise
5-Lung volumes5-Lung volumes
6-Inspiration and expiration maneuver6-Inspiration and expiration maneuver
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Factors that effect DFactors that effect DLLCO CO measurementmeasurement
7-Altitude7-Altitude
8-Oxygen concentration8-Oxygen concentration
9-Diurnal distribution9-Diurnal distribution
10-Menstrual cycle10-Menstrual cycle
11-Drinking alcohol11-Drinking alcohol
12-Sex and marital status12-Sex and marital status
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Age, height, body surface areaAge, height, body surface area
in children Din children DLLCOCO**AgeAge in elderly Din elderly DLLCOCO
** Body surface area, Body surface area, height, height, DLCO DLCOmuscle structuremuscle structure
**Weight has no effectWeight has no effect
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Cigarette smokingCigarette smoking
Chronic cigarette smoking DChronic cigarette smoking DLLCO and KCOCO and KCO
Acute smoking,Acute smoking,Occupational CO exposure alveolar CO pressureOccupational CO exposure alveolar CO pressureFrequently repeated testFrequently repeated test
**Decreased measurement due to smoking is Decreased measurement due to smoking is maksimum 10%.maksimum 10%.
**Must stop smoking at least 24 hours earlierMust stop smoking at least 24 hours earlier**Modification must be done in frequent smokersModification must be done in frequent smokers
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Hemoglobin levelHemoglobin level
Hb DHb DLLCO CO
Hb DHb DLLCOCO
-1 gram change in Hgb will change D-1 gram change in Hgb will change DLLCO 7%CO 7%
-Measured D-Measured DLLCO value: Standardized due to CO value: Standardized due to Hgb:14.6g/dLHgb:14.6g/dL
-D-DLLCO must be corrected due to changes in CO must be corrected due to changes in Hgb Hgb
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Body position and exerciseBody position and exercise
-In dawnward position-In dawnward position
the difference the difference
is %5-30is %5-30
-In upright position-In upright position
**Reason:Reason:During positional changes pulmonary blood volumeDuring positional changes pulmonary blood volume
-During exercise -During exercise
**In active persons DIn active persons DLLCO and DCO and DLLCO/VCO/VAA
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Lung VolumesLung Volumes
Volumes DVolumes DLLCO CO
To detect actual diffusion loss ;To detect actual diffusion loss ;
DDLLCO/VCO/VAA (KCO) must be (KCO) must be usedused
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Inspiration and Expiration Inspiration and Expiration ManeuversManeuvers
ValsalvaValsalva
maneuversmaneuvers
MullerMuller
effect effect
intrathoracicintrathoracic
pressurepressure
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AltitudeAltitude
Altitude Altitude FFIOIO22 D DLLCOCO **Correction may be necessaryCorrection may be necessary
Oxygen concentrationOxygen concentration
There is negative correlation between PThere is negative correlation between PAAOO2 2
and Dand DLLCOCO * * No ONo O2 2 supplemantationsupplemantation during testduring test
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Diurnal alterationDiurnal alteration
DDLLCO reaches Peak level in the morningCO reaches Peak level in the morning **During daytime During daytime progressively progressively 1-2%) per hour1-2%) per hour
Menstrual cycle and parityMenstrual cycle and parity
-~13% change during cycle -~13% change during cycle (Changes are due to Hgb effect)(Changes are due to Hgb effect)
-No significant change during parity-No significant change during parity
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Alcohol drinkingAlcohol drinking
15-30ml 95% alcohol will decrease 15-30ml 95% alcohol will decrease DDLLCO 15% after 90 minutesCO 15% after 90 minutes
Sex and ethnic conditionSex and ethnic condition
DDLLCO in men > womenCO in men > women DDLLCO whites > blacksCO whites > blacks
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CLINICAL USAGECLINICAL USAGEDecrease in DLCO ASSOCIATED WITH:Decrease in DLCO ASSOCIATED WITH:1-Obstructive lung diseases1-Obstructive lung diseases EmphysemaEmphysema Cystic fibrosisCystic fibrosis2-Parenchymal diseases2-Parenchymal diseases Interstitial pneumoniaInterstitial pneumonia Extrinsic allergic alveolitisExtrinsic allergic alveolitis Viral pneumoniaViral pneumonia Chronic interstitial fibrosis (silicos) Chronic interstitial fibrosis (silicos) Bronchioalveolar lung cancerBronchioalveolar lung cancer Drug reaction(bleomycin,nitrofurantoin)Drug reaction(bleomycin,nitrofurantoin) Alveolar proteinous and microlithyasisAlveolar proteinous and microlithyasis LymphangioleiomyomatosisLymphangioleiomyomatosis
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3-Systemic diseases effecting lung3-Systemic diseases effecting lung -Sarcoidosis-Sarcoidosis -Disseminated tuberculosis-Disseminated tuberculosis -Progressive systemic sclerosis-Progressive systemic sclerosis -RA-RA -SLE-SLE -Mixed Connective Tissue Diseases-Mixed Connective Tissue Diseases -Dermatomyositis-Polymyositis-Dermatomyositis-Polymyositis -Wegener granulomatosis-Wegener granulomatosis -Inflammatory intestinal diseases-Inflammatory intestinal diseases
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4-Cardiopulmonary diseases4-Cardiopulmonary diseases -PPH -PPH -TEAH-TEAH -Lung edema-Lung edema -Mitral stenosis-Mitral stenosis -Acute MI-Acute MI5-Othere causes5-Othere causes -Anemia -Anemia -CRF -CRF -Chronic hemodialysis -Chronic hemodialysis -BOOP-BOOP -Cocaine,marijuana-Cocaine,marijuana -Acute and chronic alcohol drinking-Acute and chronic alcohol drinking -Cigarette smoking -Cigarette smoking
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FACTORS DECREASING DLCO WHICH ARE FACTORS DECREASING DLCO WHICH ARE INDEPENDENT FROM OTHER VENTILATORY INDEPENDENT FROM OTHER VENTILATORY PARAMETERSPARAMETERS
-Interstitial diseases that don’t effect -Interstitial diseases that don’t effect airflowairflow
-Pulmonary venoocclusive diseases-Pulmonary venoocclusive diseases
-Inflamatory diseases -Inflamatory diseases
-Microembolism-Microembolism
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DLCO/VA:N -restrictionDLCO/VA:N -restriction
DLCODLCO -parenchymal -parenchymal changeschanges
DLCO/VA: -obstruction DLCO/VA: -obstruction
-dead space-dead space
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InitiallyInitially (upper field blood flow (upper field blood flow
cardiac output )cardiac output )
After progressionAfter progression:: ((V/Q equilibrium disturb)V/Q equilibrium disturb)
ASTHMAASTHMA
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CONGESTIVE HEARTH FAILURECONGESTIVE HEARTH FAILURE
Initially Initially (dilatation of pulmonary (dilatation of pulmonary
vessels)vessels)
After lung edemaAfter lung edema
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-Resection surgery D-Resection surgery DLLCOCO
-VAC -VAC
DDLLCOCO
-Bullectomy-Bullectomy
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DISEASES INCREASING DDISEASES INCREASING DLLCOCO
1-Diseases involve polystemia1-Diseases involve polystemia2-Alveolar haemorhage:Good Pasture 2-Alveolar haemorhage:Good Pasture
syndromesyndrome3-Increased pulmonary blood volume:left-3-Increased pulmonary blood volume:left-
right intracardiac shuntsright intracardiac shunts4-In Asthma, generally 4-In Asthma, generally N N
During attackDuring attack
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Diseases not effecting DDiseases not effecting DLLCOCO
1-Chest diseases1-Chest diseases
2-Pleura2-Pleura
3-Asthma3-Asthma
4-Bronchitis4-Bronchitis
5-Localised pulmonary lesions5-Localised pulmonary lesions
6-Neurofibrotic pneumoconiosis6-Neurofibrotic pneumoconiosis
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DDLLCOCO
IncreasedIncreased DecreasedDecreased
-ALVEOLAR-ALVEOLAR HAEMORRHAGEHAEMORRHAGE-POLYSTEMIA-POLYSTEMIA- DECREASE IN - DECREASE IN PULMONARY PULMONARY BLOOD VOLUMEBLOOD VOLUME
DDLLCO/VCO/VAA
NORMALNORMAL DECREASEDDECREASED
-DECREASED-DECREASEDLUNG VOLUMELUNG VOLUME-PARENCHYMAL-PARENCHYMALDESTRUCTIONDESTRUCTION
-OBSTRUCTION-OBSTRUCTION-INCREASED -INCREASED DEAD SPACEDEAD SPACE
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Indications of Diffusion CapacityIndications of Diffusion Capacity
1-Evaluation of parenchymal lung diseases1-Evaluation of parenchymal lung diseases
-organic and inorganic dust-organic and inorganic dust-drugs and lung-drugs and lung
2-Systemic diseases involve lung2-Systemic diseases involve lung
-RA-RA-Sarcoidosis-Sarcoidosis-SLE-SLE-Systemic sclerosis-Systemic sclerosis-Mixed connective tissue diseases-Mixed connective tissue diseases
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3-Obstructive lung diseases3-Obstructive lung diseases
-Differential diagnosis(asthma- -Differential diagnosis(asthma- COPD) COPD)
-Disease progression follow-up -Disease progression follow-up
-Calculation of desaturation -Calculation of desaturation during during exercise in COPD exercise in COPD
4-Cardiovascular diseases4-Cardiovascular diseases
-PPH-PPH
-TELD-TELD
-Lung edema-Lung edema
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5-Quantification of disability in interstitial 5-Quantification of disability in interstitial lung diseaseslung diseases
6-Detection of factors that increase D6-Detection of factors that increase DLLCOCO-polystemia-polystemia-pulmonary haemorrhage-pulmonary haemorrhage-left-right intracardiac shunt-left-right intracardiac shunt
7-Prediction of postoperative functional 7-Prediction of postoperative functional condition for preoperative evaluation condition for preoperative evaluation
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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PV disease
Thoracic cavity and NM diseases
ILD ve Int pneumonia
Asthma and chronic bronchitis
COPD and Emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
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ISPIROMETRY + FLOW-VOLUME CURVE
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LUNG VOLUMES
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4.134.13
DIFFUSSION CAPACITY
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DDLLCOCO
SEVERITY SEVERITY DLCO % predDLCO % pred
MILD MILD >>% 60 % 60 andand <<LLNLLN
MODERATEMODERATE % 59-40 % 59-40
SEVERESEVERE <<% 40% 40
ATS/ERS AFT Standardisation ERJ 2005;26:153-161, 319-338, 511-522,720-735,
948-968
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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PFT NORMAL, DPFT NORMAL, DLLCO DECREASEDCO DECREASED
SclerodermaScleroderma
Primary pulmonary hypertensionPrimary pulmonary hypertension
PULMONARY EMBOLISMPULMONARY EMBOLISM
VasculitisVasculitis
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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SPIROMETRYSPIROMETRY
5757
5858
LUNG VOLUMES
5959
4.64
DIFFUSIONDIFFUSION
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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SPIROMETRYSPIROMETRY
6262
FL
6363
4.67
DIFFUSIONDIFFUSION
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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FEV1/FVC %98 FVC 1.98 L %57 FEV1 1.70 L %58 TLC 3.35L %71 DLCO 22 mL/dak/mmHg %96
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PV disease
Thoracic cavity and NM disease
ILD and Int pneumonia
Asthma and chronic
bronchitis
COPD and emphysema
Normal
YES
YES
YES
YES YES YES
YES
YES
NO
NO
NO
NO
NO
NO
NO NO
Restriction Obstruction Mixed defect
Normal ?
FEV1/FVC>%70
FEV1>%80 FEV1>%80
TLC TLC
DLCO DLCO DLCO
1
2
4
3Flow-Volume
curve
5
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Diffusion TestDiffusion Test
-Correct indication-Correct indication
-Acceptable method that fits the -Acceptable method that fits the desired acceptability criterias desired acceptability criterias
-Correct comment-Correct comment