Pulmonary Function David Zanghi M.S., MBA, ATC/L, CSCS

Purpose of Pulmonary Function Testing n Pulmonary Function Testing has been a major step forward in assessing the functional status of the lungs.

n How much air volume can be moved in and out of the lungs - how large the lungs are for this patient.

n How fast the air in the lungs can be moved in and out - a question about how open the lungs are moment to moment.

n How stiff are the lungs and chest wall - a question about lung compliance

n The diffusion characteristics of the alveolar membrane through which gases must move (determined by special tests).

n How the lungs respond to chest physical therapy procedures - it will be important to have an admissions PFT and a discharge PFT performed.

Uses for PFTs n Screening for the presence of obstructive and restrictive diseases

Uses cont’d n Evaluating the patient prior to surgery : a. are older than years of age a. are older than years of age b. are known to have pulmonary disease b. are known to have pulmonary disease c. are obese c. are obese d. have a hx of smoking, cough, etc. d. have a hx of smoking, cough, etc.

Uses cont’d e. will be under anesthesia for a lengthy period of time f. are undergoing an abdominal or a thoracic operation

n Note : A vital capacity is an important preoperative assessment tool. Significant reductions in vital capacity (less than 20 cc/Kg of ideal body weight) indicates that the patient is at a higher risk for postoperative respiratory complications. This is because vital capacity reflects the patient's ability to take a deep breath, to cough, & to clear the airways of excess secretions.

Uses cont’d n Evaluating the patient's condition for weaning from a ventilator. If the patient on a ventilator can demonstrate a vital capacity (VC) of ml/Kg of body weight, it is generally thought that there is enough ventilatory reserve to permit (try) weaning & extubation.

Uses cont’d n Documenting the progression of pulmonary disease - restrictive or obstructive n Documenting the effectiveness of therapeutic interventions

Performance of the PFT n Patient Instructions : F “Take a deep breath in” F “Place the mouthpiece in your mouth” F “Create a good lip seal” F “Blow out all of the air in your lungs” F “Blow out the air as fast as you can” F “Keep blowing until I say stop”

n When three PFTs are within < 5% variance between the tests, then the testing is over.

Important Lung Volumes and Capacities n Forced Vital Capacity (FVC) Forced vital capacity is the largest volume that can be forcibly exhaled from the lungs after a profoundly deep inhalation.

n FVC is a major marker for obstructive lung disease. If FVC is low or near normal but takes a long time to exhale, obstructive disease should be expected. If FVC is low or near normal but takes a long time to exhale, obstructive disease should be expected.

n Forced Expiratory Volume in One Second (FEV1) FEV1 is the volume of air that can be forcibly exhaled in the first second of a FVC maneuver.

n FEV1 is a major marker for obstructive disease. If FEV1 is small it is a sign that either the volume of air in the lungs is small or it is difficult to blow out.

n FEV1/FVC - FEV1 Percent (FEV1%) This number is the ratio of FEV1 to FVC - it indicates what percentage of the total FVC was expelled from the lungs during the first second of forced exhalation.

n FEV1% is a very important number in determining the presence of restrictive or obstructive disease. If FEV1% is 88% - 100%, it indicates the presence of restrictive disease. If this number is 69% or lower, then the presence of obstructive disease must be expected.

n FEV3 - This is the amount of air that can be blown out of the lungs on exhalation in three seconds. In most people, FEV3 maybe very close to the actual value of FVC.

n PEFR - Peak Expiratory Flow Rate This is the maximum flow rate achieved by the patient during the forced vital capacity maneuver. It can either be measured in L/sec or L/min

n PEFR is a useful measure to see if a bronchodilatory treatment is improving obstruction as seen in asthma where there is lots of bronchoconstriction.

n Forced Expiratory Flow 25% - 75% This measurement describes the amount of air expelled from the lungs during the middle half of the forced vital capacity test.

n Many physicians like to look at FEF25%-75% because it is an indicator of obstructive disease.

Obstructive Diseases n Emphysema n Bronchitis n Bronchiectasis n Asthma

How Do I Determine The Extent Of Lung Disease ? n How do I determine if the patient has mild, moderate or severe lung disease ?

n Normal PFT Outcomes - > 85 % of predicted values n Mild Disease - > 65 % but 65 % but < 85 % of predicted values n Moderate Disease - > 50 % but 50 % but < 65 % of predicted values n Severe Disease - < 50 % of predicted values

Reversible Lung Disease n If 2 or more of the PFT variables change after a bronchodilator treatment, then the patient has reversible disease.

What is Acceptible Change ? 1.FVC : an increase of 10% or more 2.FEV1 : an increase of 200 ml or 15% of the baseline FEV1 3.FEF25%-75% : an increase of 20% or more

How Do I Read A PFT ? n Step 1. Look at the forced vital capacity (FVC) to see if it is within normal limits. n Step 2. Look at the forced expiratory volume in one second (FEV1) and determine if it is within normal limits.

n Step 3. If both FVC and FEV1 are normal, then you do not have to go any further - the patient has a normal PFT test.

n Step 4. If FVC and/or FEV1 are low, then the presence of disease is highly likely.

n Step 5. If Step 4 indicates that there is disease then you need to go to the %predicted for FEV1/FVC.

n If the %predicted for FEV1/FVC is 88%-90% or higher, then the patient has a restricted lung disease. If the %predicted for FEV1/FVC is 69% or lower, then the patient has an obstructed lung disease.

Example # 1 Predicted Measured %Predicted FVC 5.80 L 5.50 L 95% FEV L 4.90 L 99% FEV1% 85% 89% 104%

Example # 2 Predicted Measured %Predicted FVC 5.68 L 4.00 L 70% FEV L 3.25 L 66% FEV1% 84% 81% 96%

Example # 3 Predicted Measured %Predicted FVC 4.50 L 2.63 L 58% FEV L.80 L 21% FEV1% 84% 30% 36%