Pulmonary Function Testing

1. Pulmonary Function Testing Dr Simon Donoghue Product Support Manager VIASYS Healthcare

2. Schedule 9.30 – 10.30 Introduction and Spirometry 10.30 – 11.00 Coffee 11.00 – 12.00 Lung Volumes 12.00 – 13.00 Lunch 13.00 – 14.00 Transfer Factor/ Diffusion 14.00 – 14.30 Coffee 14.30 – 16.00 Airways Resistance

3. VIASYS Healthcare

4. The Basics….. • How fast we can breathe in/out • How much we can breathe in/out • How easily gas can pass from lungs to blood • How big our lungs are • Airways resistance • Exercise

5. Spirometry

6. 1846 J. Hutchinson „VC“ 1950 Tiffeneau „V (t), FVC, FEV1“ History of Lung Function

7. Mass Flow Sensor

8. Pneumotachograph P P Lilly Type Flow Transducer

9. CALIBRATION (ATP-BTPS) Temperature has the highest influence on the volume change between in- and expiration. New entry required if room temperature changes more than 2 degrees, or humidity varies from above than 10 %.

10. Effects of atmospheric conditions • If we are testing in sunny Stockholm, in icy conditions (-25oC) breathe in 4 litres and expire 5.4 litres! • If we test in a warm lab (20oC) breathe in 4 litres and expire 4.4 litres • If we test in the Middle East (49oC) breathe in 4 litres breathe out 3.75 litres

11. Spirometry Determination of static and dynamic parameters of the lung. V’

12. Why Perform Spirometry

13. Value of Spirometry Differentiation of the lung function Is it a relevant ventilatory disorder? Is it an obstructiveorrestrictive ventilatory disorder? Responsiveness of the bronchial system Is the bronchial system hyperreactive? Is the airway obstruction completely or at least partially reversible? Long term observation How lung function values change with therapy/time?

14. Respiratory Disorder Groups Obstructive ventilatory disorders The width of the tracheobronchial tree (lumen, mural properties, flow). Restrictive ventilatory disorders The static and dynamic properties of lung and thoracic wall. Neuromuscular ventilatory disorders The efficiency of the “breathing pump”, the diaphragm and the thoracic muscles

15. Obstructive Ventilatory Disorder Increased airway resistance, because the decreased airway calibre, limits lung ventilation.

16. COPD Lung

17. Asthmatics Airway

18. CysticFibrosis Lung 18

19. Restrictive Ventilatory Disorder Restricted elasticity of lung and/or thorax combined with reduced lung volume.

20. What Do We Measure?

21. Guidelines for withholding medications: Inhaled bronchodilators Short-acting 4 to 8 hours Long-acting 24 hours Anticholinergics 6 hours Oral short-acting bronchodilators 8 hours Sustained-release beta agonists 24 hours Theophylline Twice-daily preparations 24 hours Once-daily preparations 48 hours

22. SPRIOMETRY • FEV1 (Forced Expired Volume in 1 sec) The volume of air that can be exhaled in the first second of expiration • FVC (Forced Vital Capacity) The total volume of air that can be exhaled.

23. FEV1 and FVC 5 4 3 2 1 Volume (Litres) In Normal Subjects FEV1 / FVC >= 80% 0 1 2 3 4 5 6 Time (sec)

24. OBSTRUCTIVE In Obstructive Patients FEV1 / FVC < 80% 5 4 3 2 1 Volume (Litres) 0 1 2 3 4 5 6 Time (sec)

25. RESTRICTIVE 5 4 3 2 1 Volume (Litres) In Restrictive Patients FEV1 / FVC >= 80% 0 1 2 3 4 5 6 Time (sec)

26. Flow Volume Loops

27. Flow Volume Loops • Give us more information about the disorder. • Can differentiate intra/extra-thoracic obstruction and to a lesser extent central/peripheral obstruction.

28. Flow-Volume (ECCS/ERS)

29. Recommended breathing manoeuvre • At first the patient is spontaneously breathing(adaptation phase) • On instruction a SLOW AND DEEP EXPIRATION should be performed down to RV-level - plateau must be visible in volume trend - • The inspirationmaximal AND forcedup to TLC • Without pause the patient expires as rapid and as deep as possible (Supporting verbal encouragement is absolutely necessary!) • The test is terminated by a deep inspiration or spontaneous breathing again (recovery phase)

30. Spirometry Example

31. Spirometry and Time

32. Spirometry and Flow

33. Flow-Volume (ECCS/ERS)

34. F/V - Parameters • Volume:FVC Forced vital capacity • VCin Inspiratory vital capacity • FEV 1 Forced volume in 1 sec • Flows:PEF Peak flow (ex) • MEF75 Max ex-flow at 75% VCin • MEF50 Max ex-flow at 50% VCin • MEF25 Max ex-flow at 25% VCin • MIF50 Max in-flow at 50% VCin • Relative volumes:FEV1 % VCin • FEV1 % FVC • FEV1 % VCmax

35. Obstruction

36. Obstruction • In obstruction we see reduced MEF 25-75 • In moderate/severe obstruction see reduced PEF • In moderate/severe obstruction see reduced FVC

37. Restriction

38. Restriction • FVC significantly reduced • PEF and MEF reduced accordingly

39. Airway Dynamics EXPIRATION

40. Airway Dynamics INSPIRATION

41. INTRA/EXTRA-THORACIC • Patients with INTRA-THORACIC obsrtuction have EXPIRATORY LIMITATIONS • Patients with EXTRA-THORACIC obsrtuction have INSPRATORY LIMITATIONS

42. Vocal Cord Dysfunction

43. Intrathoracic Stenosis

44. Fixed Stenosis

45. Europe/US Differences

46. Flow-Volume (ECCS) ECCS (VCin)

47. Flow-Volume (ATS) ATS (FVC)

48. On instruction a SLOW AND DEEP EXPIRATION should be performed down to RV-level

49. Flow-Volume (ATS) ECCS (VCin) vs.ATS (FVC)

50. FVC or VCin ?? ATS: Lung function testing: Selection of reference values and interpretative strategies Am Rev Respir Dis 144 (1991) 1202 – 1218 page 1212: ... VC, FEV1 and FEV1/VC .... Although FVC is often used in place of VC it is preferable to use the largest VC, whether obtained on inspiration (IVC), slow expiration (EVC) or forced expiration .... The FVC is usually reduced more than IVC or EVC in airflow obstruction.