 Lungs comprised of ◦ Airways ◦ Alveoli

Weibel ER: Morphometry of the Human Lung. Berlin and New York: Springer- Verlag, 1963  Conducting zone: no gas exchange occurs ◦ Anatomic dead space  Transitional zone: alveoli appear, but are not great in number  Respiratory zone: contain the alveolar sacs

 Approximately 300 million alveoli  1/3 mm diameter  Total surface area if they were complete spheres 85 sq. meters (size of a tennis court) Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed., Copyright © 2000 W. B. Saunders Company

 Inspiration ◦ Active process  Expiration ◦ Quiet breathing: passive ◦ Can become active

IRV TV ERV  4 Volumes  4 Capacities ◦ Sum of 2 or more lung volumes RV IC FRC VC TLC RV

IRV TV ERV RV IC FRC VC TLC RV  Volume of air inspired and expired during normal quiet breathing

IRV TV ERV  The maximum amount of air that can be inhaled after a normal tidal volume inspiration RV IC FRC VC TLC RV

IRV TV ERV  Maximum amount of air that can be exhaled from the resting expiratory level RV IC FRC VC TLC RV

IRV TV ERV  Volume of air remaining in the lungs at the end of maximum expiration RV IC FRC VC TLC RV

IRV TV ERV  Volume of air that can be exhaled from the lungs after a maximum inspiration  FVC: when VC exhaled forcefully  SVC: when VC is exhaled slowly  VC = IRV + TV + ERV RV IC FRC VC TLC RV

IRV TV ERV  Maximum amount of air that can be inhaled from the end of a tidal volume  IC = IRV + TV RV IC FRC VC TLC RV

IRV TV ERV  Volume of air remaining in the lungs at the end of a TV expiration  The elastic force of the chest wall is exactly balanced by the elastic force of the lungs  FRC = ERV + RV RV IC FRC VC TLC RV

IRV TV ERV  Volume of air in the lungs after a maximum inspiration  TLC = IRV + TV + ERV + RV RV IC FRC VC TLC RV

 Term used to indicate a battery of studies or maneuvers that may be performed using standardized equipments to measure lung function

 Detect disease  Evaluate extent and monitor course of disease  Evaluate treatment  Measure effects of exposures  Assess risk for surgical procedures

FEV1 IN COPD OCCUPATIONAL EXPOSURES

 Measurement of the pattern of air movement into and out of the lungs during controlled ventilatory maneuvers.  Often done as a maximal expiratory maneuver

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 Should not smoke within at least 4 h of testing  Should not consume alcohol within 4 h of testing  Should not performe vigorous exercise within 30 min of testing  Should not wear strict clothes  Should not eat a large meal within 2 hours of testing  Bronchodilator medications? Before test 23

 Sitting or standing position  Upright sitting  Nose clip  Army chair  Wheelchair?  Obesity?  False teeth? During test 24

 Should be rested 5-10 min.  Should be relaxed  Should be informed on tests During test 25

 Dynamic studies: spirometry, flow volume loop, PEF  Static lung volumes  Diffusing capacity  Bronchodilator test 26

No artefacts on spirogram:  Should not cough  Should not close glottis within 1s of exhalation  Should not terminate test early  Should not perform variable effort  Should not leak from mouthpiece  Should not close of openness by mouthpiece 27

Extrapolation volume BACK EXTRAPOLATION ZERO TIME (EV) EXTRAPOLATED VOLUME MAXIMAL INSPIRATORY LEVEL TIME, s VOLUME, L Ekstrapolation volume must be < 5% of FVC or L A pause of < 1s at TLC after inspirium 28

 Have patient seated comfortably  Closed-circuit technique ◦ Place nose clip on ◦ Have patient breathe on mouthpiece ◦ Have patient take a deep breath as fast as possible ◦ Blow out as hard as they can until you tell them to stop

 Forced vital capacity (FVC): ◦ Total volume of air that can be exhaled forcefully from TLC ◦ The majority of FVC can be exhaled in <3 seconds in normal people, but often is much more prolonged in obstructive diseases ◦ Measured in liters (L)

 Forced expiratory volume in 1 second: (FEV 1 ) ◦ Volume of air forcefully expired from full inflation (TLC) in the first second ◦ Measured in liters (L) ◦ Normal people can exhale more than 75-80% of their FVC in the first second; thus the FEV1/FVC can be utilized to characterize lung disease

 % normal  70-79% mild obstruction  51-69% moderate obstruction  <50% severe obstruction

 Forced expiratory flow 25-75% (FEF ) ◦ Mean forced expiratory flow during middle half of FVC ◦ Measured in L/sec ◦ May reflect effort independent expiration and the status of the small airways ◦ Highly variable ◦ Depends heavily on FVC

 Interpretation of % predicted: ◦ >60%Normal ◦ 40-60%Mild obstruction ◦ 20-40%Moderate obstruction ◦ <10%Severe obstruction

 Illustrates maximum expiratory and inspiratory flow- volume curves  Useful to help characterize disease states (e.g. obstructive vs. restrictive) Ruppel GL. Manual of Pulmonary Function Testing, 8 th ed., Mosby 2003

Exhalation:  Exhalation time must be  6s and/or a plateau must be seen in volume time curve  The patient cannot continue further exhalation  No change in volume for  1 s at the end of exhalation  Time could be prolonged in patients with obstruction or older subjects 36

37  Volume –time display  Flow- volume display

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Acceptable Spirogram Volume-Time Flow-Volume 40

Cough in 1second Volume-Time Flow-Volume 41

Glottic closure Volume-Time Flow-Volume 42

Variable effort Early termination Volume-TimeFlow-Volume 43

Air leak Volume-Time Flow-Volume 44

Three acceptable spirograms The largest values of FVC must be < L of each other The largest values of FEV 1 must be < L For those with an FVC of ≤ 1 L both these values are 0.100L If both of these criteria do not meet Continue testing until Both criteria are met with acceptable spirograms A total 8 tests have been performed The patient cannot continue Spirometry Acceptability Criterias ATS/ERS Task Force

 Three tests with acceptable start of test and free from artefact are selected and saved  The largest FVC and the largest FEV 1 should be recorded and FEV 1 /FVC should be calculated 46

Test appropriate for the repeatability criterias Flow-Volume Volume-Time 47

TEKRARLANABİLİRLİK Volume-Time Flow-Volume Tekrarlanabilirlik Kriterine Uygun Olmayan Test Test not appropriate for the repeatability criterias 48

 Obstructive  Restrictive  Mixed

 Characterized by a limitation of expiratory airflow ◦ Examples: asthma, COPD  Decreased: FEV 1, FEF 25-75, FEV 1 /FVC ratio (<0.8)  Increased or Normal: TLC

 Slow rise in upstroke  May not reach plateau

 Characterized by diminished lung volume due to: ◦ change in alteration in lung parenchyma (interstitial lung disease) ◦ disease of pleura, chest wall (e.g. scoliosis), or neuromuscular apparatus (e.g. muscular dystrophy)  Decreased TLC, FVC  Normal or increased: FEV 1 /FVC ratio

 Rapid upstroke as in normal spirometry  Plateau volume is low

 Characterized by a truncated inspiratory or expiratory loop

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