Ms. Namita Jadhao. M.Sc Nursing final year.

Classification of PFTs
I. Tests to assess Ventilator function: 1. Elastic Properties a) Lung volume I) Spirometry ii) Body Plethysmography iii) Gas Dilution b) Elastic Resistance of Lungs c) Elastic Resistance of Chest Wall d) Elastic Resistance of Lung + Chest Wall

2. Airway Function a) Airway Resistance b) Forced Vital Capacity c) Maximum Voluntary Ventilation d) Post bronchodilator Studies e) Airway Provocation 3. Respiratory Muscle Function

II. Tests to assess blood & gas distribution and of gas exchange: 1. Intrapulmonary Gas Distribution a) Multiple-Breath Dilution Techniques b) Single-Breath Dilution Techniques c) Frequency Dependence of Compliance 2. Pulmonary Blood Flow Distribution 3. Diffusion a) Steady-State CO Diffusing Capacity b) Single-Breath CO Diffusing Capacity c) Pulmonary Capillary Blood

4. Assessment of Gas Exchange a) Blood & Gas Sampling & Analysis b) Calculation of Parameters of Gas Exchange i) O2 Consumption ii) CO2 Production iii) Respiratory Quotient iv) Physiologic Dead Space 5. Acid-Base Status 6. Response to Exercise 7. Chemical Regulation of Respiration

Assessment of ventilation
1. ELASTIC PROPERTIES OF LUNG: a) Lung volumes & capacities Measured using (i) Spirometer, (ii) Plethysmograph, (iii) Gas dilution techniques

Spirogram

Lung Volumes: 1. Tidal Volume 2. Inspiratory Reserve Volume 3. Expiratory Reserve Volume 4. Residual Volume Lung Capacities: 1. Inspiratory Capacity 2. Functional Residual Capacity 3. Vital Capacity 4. Total Lung Capacity

Body Plethysmography: Based on Boyles Law P1 x TGV = (P1 + Pm) (TGV + Vp) where P1- initial pressure Pm- mouth or airway pressure Vp- volume in box TGV- Thoracic Gas Volume

Gas Dilution: Insoluble gases like helium, hydrogen or nitrogen is used. FRC, RV and TLC can be measured. i) Multiple breath Helium Technique FRC = (VS + VDS) (FIHE FEHE) FEHE Where VS- initial vol of gas in spirometer VDS- dead space of the system FIHE- initial He concentration FEHE- He conc at equilibrium

ii) Single-Breath Helium Technique TLC x FEHE = (VC x FIHE) + (RV x FOHE) Where TLC- total lung capacity VC- vital capacity RV- residual volume FEHE- He conc at equilibrium FIHE- initial He concentration FOHE- He conc in lungs at onset of inspiration

iii) Multiple-Breath N2 washout Closed circuit 100% O2 breathing for 7mins iv) Single-Breath N2 Clearance
80

N2 conc (%)

30 20

CV
10

RV

TLC

30% VC

0 1 2 3 4 5
RV

6 Volume (L)

Vital Capacity

b) Elastic Resistance of lung i) Transpulmonary Pressure ii) Airflow & Volume- using pneumotachogram and spirometer iii) Compliance of lung- Static & Dynamic c) Elastic Resistance of total pulm system Relaxation Pressure-Volume Curve d) Elastic Resistance of Chest Wall 1/CT = 1/CL + 1/CCW

2. AIRWAY FUNCTION: a) Airway Resistance Measured using plethysmograph Raw = Pm/ V b) Forced Vital Capacity Slow inhalation to TLC and fast & hard exhalation to RV (6 sec) FEV1- 85%; FEV2- 93%; FEV3- 98 to 100%

c) Maximum Voluntary Ventilation Breathe hard and fast for 12secs & multiply by 5. d) Postbronchodilator Studies When spirometry and other tests show airflow limitation e) Airway Provocation To check airway hyper-responsiveness Histamine, Methacholine, Cold air, Exercise, Occupational irritants Aspirin, Tartrazine, Sodium salicylate, etc

3. Respiratory Muscle Function a) Mechanical work of breathing: pressurevolume loop b) Metabolic work of breathing: by measuring increment of O2 consumption with increment in minute ventilation c) Efficiency of respiratory system Mechanical work/Metabolic work d) Respiratory muscle strength MEP/MIP, Pdimax, Sniff test e) Respiratory muscle endurance f) Respiratory muscle fatigue

ASSESSMENT OF BLOOD & GAS DISTRIBUTION AND OF GAS EXCHANGE

1. Intrapulmonary gas distribution: a) Multiple Breath Dilution Techniques i) mixing efficiency for helium ii) nitrogen washout b) Single-Breath Dilution Techniques i) regional distribution- xenon133- scintillation camera ii) single-breath nitrogen test c) Frequency Dependence of Compliance

2. Pulmonary Blood Flow Distribution: Dye dilution principle Fick Principle Radioactive iodine labeled albumin Radioactive Xenon 3. Diffusion: a) Steady state CO diffusing capacity b) Single-breath CO diffusing capacity

4. Assessment of gas exchange: a) Blood & gas sampling and analysis Arterial blood sampling- Radial or brachial arteries Gas analysis- by using electrodesreported at body temperature Oxygen electrode- silver anode & platinum wire cathode- oxygen is reduced when voltage is appliedelectrons pass from cathode to anodemeasured by galvanometer pH and CO2 electrodes

5. Calculation of parameters of gas exchange: a) Oxygen consumption b) CO2 production c) Respiratory Quotient d) Physiologic dead space
6. Acid Base Status 7. Response to exercise

Interpretation of PFT
Interpretation of ventilatory function tests: Lung volume compartments differ with age, gender, race and height Lung volume and capacity measurements give an idea about restrictive & obstructive disorders. Reduced FRC, RV & TLC volumepressure curve shifted to right & downwards reduced compliance of lung and/or chest wall

 Increased FRC, RV & TLC overdistension volume-pressure curve shifted to left and upwards obstructive airway disease

Normal FRC + increased RV + reduced TLC mixed disorder Vital capacity is used as surrogate to TLC

 Low FEV1 & normal FEV1/FVC ratio suggest restrictive disorder Low FEV1 & low FEV1/FVC suggest obstructive disorder

8 Flow rate l/sec

RESTRICTIVE PATTERN

0 6
IC

3
ERV

2
RV

8 OBSTRUCTIVE PATTERN

0 6 5 4 3 2

Lung volume (L)

 FEF25-75 and FEV1 may be normal in increased peripheral airway resistance. Closing volume and closing capacity are rarely used clinically On using bronchodilator, FEV1/FEF25-75 must improve by atleast 15% to tell obstruction is reversible
Reduced PImax/Pdimax/PEmax may also suggest poor effort by the subject

Interpretation of blood gases and gas exchange: Respiratory quotient of <0.65 and >0.95 indicate hypo- and hyperventilation respectively P(A-a)O2 is <15mm Hg normally Low PaO2 with increased P(A-a)O2 with or without abnormal PaCO2 indicate abnormality of gas exchange

 VD/VT is 30% in young and 40% in aged. Greater than this, it indicates dead-spacelike ventilation. Venous admixture like perfusion- low VA/Q- physiologic shunt True venous admixture- PaO2 fails to raise above 500 mm Hg on breathing 100% oxygen Low DLCO is seen in diffuse pulmonary fibrosis, pneumonectomy, end-stage emphysema

 Acid-Base balance: blood pH of 7.35-7.45, bicarbonate level of 20-27 mEq and PaCO2 between 40-45 mm Hg at sea level.

Respiratory acidosis

alveolar ventilation

COPD

Anaesthetics, Narcotics. Mopathies, Neuropathies. Kyphoscoliosis, Obesity.

Respiratory alkalosis alveolar ventilation Salicylates, progesterone. Excessive mechanical ventilation. Psychogenic, fever Diabetic ketoacidosis, starvation Primary lactic acidosis ARF, CRF, RTA Diarrhoea Antacid ingestion Vomiting, gastric suction Diuretics, steroid therapy

High PaCO2. Low pH. Normal or high HCO3-.

Low PaCO2. High pH. Normal or low HCO3-

Metabolic acidosis

Gain of H+ or loss of HCO3- by ECF

Low HCO3-. Low pH. Normal or high PaCO2..

Metabolic alkalosis

Gain of HCO3- or loss of H+ by ECF

High HCO3-. High pH. Normal or high PaCO2.