MAKING SENSE of Lung Function Tests Second edition A hands-on guide MAKING SENSE of Lung Function Tests Second edition A hands-on guide Jonathan Dakin, MD FRCP BSc Hons Consultant Respiratory Physician Royal Surrey County Hospital NHS Foundation Trust Surrey, UK Honorary Consultant Respiratory Physician Portsmouth Hospitals NHS Trust Hampshire, UK Mark Mottershaw, BSc Hons MSc Chief Respiratory Physiologist Queen Alexandra Hospital Portsmouth Hospitals NHS Trust Hampshire, UK Elena Kourteli, FRCA Consultant Anaesthetist St George’s University Hospitals Foundation NHS Trust London, UK CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4822-4968-2 (Paperback) This book contains information obtained from authentic and highly regarded sources Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Library of Congress Cataloging-in-Publication Data A catalog record of this book is on file with the Library of Congress Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Ὁ μεν βίος βραχὺς, ἡ δὲ τέχνη μακρὴ, ὁ δὲ καιρὸς ὀξὺς, ἡ δὲ πεῖρα σφαλερὴ, ἡ δὲ κρίσις χαλεπή Ἱπποκράτης Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult Hippocrates Contents Preface xv Acknowledgement xv Abbreviations Expressions of normality PART TESTS OF AIRWAY FUNCTION AND MECHANICAL PROPERTIES Peak expiratory flow Introduction Test description and technique Pitfalls Physiology of test Normal values Peak flow variability in the diagnosis of asthma Assessment and management of asthma Pitfall Spirometry and the flow–volume loop Introduction Measured indices and key definitions Test description and technique Physiology of tests Restrictive and obstructive defects Restrictive defects Obstructive defects Maximum expiratory flows Normal values Assessment of severity of obstruction Mid-expiratory flows xvii 7 7 8 11 12 13 13 13 13 16 16 16 18 18 20 21 22 vii viii Contents FVC versus VC Patterns of abnormality Obstructive spirometry Restrictive spirometry Reduction of FEV1 and FVC Mixed obstructive/restrictive defect Non-specific ventilatory defect Large airways obstruction Fixed upper airway obstruction Variable extrathoracic obstruction Variable intrathoracic obstruction Clinical pearls Airway responsiveness Introduction Test physiology Test descriptions Reversibility Challenge testing Interpretation of results Reversibility Challenge testing Fractional concentration of expired nitric oxide Introduction Test description/technique Physiology of test Normal values and interpretation Specific considerations Gas transfer Introduction Measured indices/key definitions Alveolar volume K CO Test description Physiology of gas exchange Normal values Patterns of abnormality Incomplete lung expansion Discrete loss of lung units Diffuse loss of lung units 23 23 23 25 27 27 28 29 29 29 31 31 35 35 35 36 36 37 37 37 38 41 41 41 42 43 44 45 45 45 46 46 47 48 48 49 49 51 52 Contents ix Pulmonary emphysema Pulmonary vascular disease Causes of increased gas transfer Clinical pearls Interstitial lung disease Obstructive disease Acute disease Static lung volumes and lung volume subdivisions Introduction Measured indices/key definitions Test descriptions/techniques Helium dilution Nitrogen washout Whole-body plethysmography Comparison of methods Physiology of lung volumes Total lung capacity Residual volume Functional residual capacity Closing capacity Normal values Patterns of abnormality Relationship between VC and TLC Obstructive lung disease Interstitial lung disease Miscellaneous Specific considerations Anaesthesia FRC in patients receiving ventilatory support: PEEP and CPAP Clinical pearls Airway resistance Introduction Physiology of airway resistance tests Plethysmography technique Test description/technique Measured indices/key definitions Normal values Patterns of abnormality 52 53 54 54 54 55 56 57 57 57 59 59 61 61 63 64 64 64 64 65 65 66 67 67 67 68 68 68 68 70 73 73 74 75 75 76 76 76 190 References 12 Dykstra BJ, Scanlon PD, Kester MM, et al Lung volumes in 4,774 patients with obstructive lung disease Chest 1999;115(1):68–74 13 Hyatt RE, Scanlon PD, Nakamura M Interpretation of Pulmonary Function Tests, 4th edition Philadelphia, PA: Lippincott Williams and Wilkins, 2014 14 Kannel WB, Hubert H, Lew EA Vital capacity as a predictor of cardiovascular disease: The Framingham study Am Heart J 1983;105(2):311–5 15 Holleman DR, Jr., Simel DL Does the clinical examination predict airflow limitation? JAMA 1995;273(4):313–9 16 Crapo RO, Casaburi R, Coates AL, et al Guidelines for methacholine and exercise challenge testing-1999 This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999 Am J Respir Crit Care Med 2000;161(1):309–29 17 Sterk PJ, Fabbri LM, Quanjer PH, et al Airway responsiveness Standardized challenge testing with pharmacological, physical and sensitizing stimuli in adults Report working party standardization of lung function tests, European community for steel and coal Official statement of the European respiratory society Eur Respir J Suppl 1993;16:53–83 18 Newton MF, O’Donnell DE, Forkert L Response of lung volumes to inhaled salbutamol in a large population of patients with severe hyperinflation Chest 2002;121(4):1042–50 19 American Thoracic Society, European Respiratory Society ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005 Am J Respir Crit Care Med 2005;171(8):912–30 20 Dweik RA, Boggs PB, Erzurum SC, et al An official ATS clinical practice guideline: Interpretation of exhaled nitric oxide levels (FENO) for clinical applications Am J Respir Crit Care Med 2011;184(5):602–15 21 Hughes JM, Pride NB Examination of the carbon monoxide diffusing capacity (DLCO) in relation to its KCO and VA components Am J Respir Crit Care Med 2012;186(2):132–9 22 Gibson G Lung volumes and elasticity In: Hughes J, Pride N, eds Lung Function Tests Physiological Principles and Clinical Applications, 1st edition London: WB Saunders, 1999, pp 45–57 23 Aaron SD, Dales RE, Cardinal P How accurate is spirometry at predicting restrictive pulmonary impairment? Chest 1999;115(3):869–73 24 Casanova C, Cote C, de Torres JP, et al Inspiratory-to-total lung capacity ratio predicts mortality in patients with chronic obstructive pulmonary disease Am J Respir Crit Care Med 2005;171(6):591–7 References 191 25 Mottram CD Ruppel’s Manual of Pulmonary Function Testing, 11th edition St Louis, MO: Elsevier, 2017 26 Oostveen E, MacLeod D, Lorino H, et al ERS Task Force on Respiratory Impedance Measurements The forced oscillation technique in clinical practice: Methodology, recommendations and future developments Eur Respir J 2003;22:1026–41 27 Allen SM, Hunt B, Green M Fall in vital capacity with posture Br J Dis Chest 1985;79(3):267–71 28 Steier J, Kaul S, Seymour J, et al The value of multiple tests of respiratory muscle strength Thorax 2007;62(11):975–80 29 Ragette R, Mellies U, Schwake C, et al Patterns and predictors of sleep disordered breathing in primary myopathies Thorax 2002;57(8):724–8 30 Berry R, Brooks R, Gamaldo CE et al for the American Academy of Sleep Medicine The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version Darien, IL: American Academy of Sleep Medicine 2015 31 Dohna-Schwake C, Ragette R, Teschler H, et al Predictors of severe chest infections in pediatric neuromuscular disorders Neuromuscul Disord 2006;16(5):325–8 32 Lyall RA, Donaldson N, Polkey MI, et al Respiratory muscle strength and ventilatory failure in amyotrophic lateral sclerosis Brain 2001;124(Pt 10):2000–13 33 Morgan RK, McNally S, Alexander M, et al Use of Sniff nasal-inspiratory force to predict survival in amyotrophic lateral sclerosis Am J Respir Crit Care Med 2005;171(3):269–74 34 Hull J, Aniapravan R, Chan E, et al British Thoracic Society guideline for respiratory management of children with neuromuscular weakness Thorax 2012;67(Suppl 1):i1–i40 35 Szeinberg A, Tabachnik E, Rashed N, et al Cough capacity in patients with muscular dystrophy Chest 1988;94(6):1232–5 36 Estenne M, De Troyer A Mechanism of the postural dependence of vital capacity in tetraplegic subjects Am Rev Respir Dis 1987;135(2):367–71 37 Lim BL, Kelly AM A meta-analysis on the utility of peripheral venous blood gas analyses in exacerbations of chronic obstructive pulmonary disease in the emergency department Eur J Emerg Med 2010;17(5):246–8 38 Crossley DJ, McGuire GP, Barrow PM, et al Influence of inspired oxygen concentration on deadspace, respiratory drive, and PaCO2 in intubated patients with chronic obstructive pulmonary disease Crit Care Med 1997;25(9):1522–6 192 References 39 Davidson AC, Banham S, Elliott M, et al BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults Thorax 2016;71(Suppl 2):ii1–ii35 40 Van de Louw A, Cracco C, Cerf C, et al Accuracy of pulse oximetry in the intensive care unit Intensive Care Med 2001;27(10):1606–13 41 McKeever TM, Hearson G, Housley G, et al Using venous blood gas analysis in the assessment of COPD exacerbations: A prospective cohort study Thorax 2016;71(3):210–5 42 Hardinge M, Annandale J, Bourne S, et al British Thoracic Society guidelines for home oxygen use in adults Thorax 2015;70(Suppl 1):i1–i43 43 Zavorsky GS, Cao J, Mayo NE, et al Arterial versus capillary blood gases: A meta-analysis Respir Physiol Neurobiol 2007;155(3):268–79 44 Eaton T, Rudkin S, Garrett JE The clinical utility of arterialized earlobe capillary blood in the assessment of patients for long-term oxygen therapy Respir Med 2001;95(8):655–60 45 Lumb AB Nunn’s Applied Respiratory Physiology, 8th edition London: Elsevier, 2016 46 Brandis K Acid-base physiology (updated 30 August 2015) Available from: http://www.anaesthesiaMCQ.com 47 Graham T Acid base online tutorial 2006 (cited 2016) Available from: http://fitsweb.uchc.edu/student/selectives/TimurGraham/Welcome.html 48 Holland AE, Spruit MA, Troosters T, et al An official European Respiratory Society/American Thoracic Society technical standard: Field walking tests in chronic respiratory disease Eur Respir J 2014;44(6):1428–46 49 ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories ATS statement: Guidelines for the six-minute walk test Am J Respir Crit Care Med 2002;166(1):111–7 50 Casanova C, Celli BR, Barria P, et al The 6-min walk distance in healthy subjects: Reference standards from seven countries Eur Respir J 2011;37(1):150–6 51 Probst VS, Hernandes NA, Teixeira DC, et al Reference values for the incremental shuttle walking test Respir Med 2012;106(2):243–8 52 Celli BR, Cote CG, Marin JM, et al The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease N Engl J Med 2004;350(10):1005–12 53 Wasserman K Diagnosing cardiovascular and lung pathophysiology from exercise gas exchange Chest 1997;112(4):1091–101 References 193 54 Older P, Hall A, Hader R Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly Chest 1999;116(2):355–62 55 Tanaka H, Monahan KD, Seals DR Age-predicted maximal heart rate revisited J Am Coll Cardiol 2001;37(1):153–6 FURTHER READING GENERAL RESPIRATORY PHYSIOLOGY Lumb A Nunn’s Applied Respiratory Physiology, 8th edition London: Elsevier, 2017 West JB West’s Respiratory Physiology: The Essentials, 10th edition Baltimore, MD: Lippincott Williams and Wilkins, 2015 RESPIRATORY MEDICINE/PATHOPHYSIOLOGY Chapman S, Robinson G, Stradling J, West S, Wrightson J Oxford Handbook of Respiratory Medicine (Oxford Medical Handbooks), 3rd edition London: Oxford University Press, 2014 West JB Pulmonary Pathophysiology: The Essentials, 10th edition Baltimore, MD: Lippincott Williams and Wilkins, 2015 REFERENCE VALUES Quanjer PH, Stanojevic S, Cole TJ, et al Multi-ethnic reference values for spirometry for the 3–95-yr age range: The global lung function 2012 equations Eur Respir J 2012;40:1324–43 GENERAL LUNG FUNCTION British Thoracic Society Guidelines for the measurement of respiratory function Respir Med 1994;88:165–94 Brusasco V, Crapo R, Viegi G, eds ATS/ERS task force: Standardisation of lung function testing General considerations for lung function testing Eur Respir J 2005;26:153–61 Cooper B, Evans A, Kendrick A, Newall C, (eds) The ARTP Practical Handbook of Respiratory Function Testing – Parts and Boldmere: Association for Respiratory Technology and Physiology, 2003 Cotes JE, Chinn DJ, Miller MR Lung Function: Physiology, Measurement and Application in Medicine, 6th edition Oxford: Wiley-Blackwell, 2006 194 References Gibson GJ Clinical Tests of Respiratory Function, 3rd edition London: Hodder Arnold, 2008 Hughes JMB Physiology and Practice of Pulmonary Function Boldmere: Association for Respiratory Technology and Physiology, 2009 Hyatt RE, Scanlon PD Interpretation of Pulmonary Function Tests: A Practical Guide, 3rd edition Baltimore, MD: Lippincott Williams and Wilkins, 2008 Mottram C Ruppel’s Manual of Pulmonary Function Testing, 10th edition St Louis, MO: Mosby Elsevier, 2012 SPIROMETRY Brusasco V, Crapo R, Viegi G, eds ATS/ERS task force: Standardisation of lung function testing—Standardisation of spirometry Eur Respir J 2005;26:319–38 GAS TRANSFER Brusasco V, Crapo R, Viegi G, eds ATS/ERS task force: Standardisation of lung function testing Standardisation of the single-breath determination of carbon monoxide uptake in the lung Eur Respir J 2005;26:720–35 Fitting JW Transfer factor for carbon monoxide: A glance behind the scene Swiss Med Wkly 2004;134:413–8 LUNG VOLUMES Brusasco V, Crapo R, Viegi G, eds ATS/ERS task force: Standardisation of lung function testing Standardisation of the measurement of lung volumes Eur Respir J 2005;26:511–22 CHALLENGE TESTING ERS Task Force Indirect airway challenges Eur Respir J 2003;21:1050–68 RESPIRATORY MUSCLE FUNCTION American Thoracic Society/European Respiratory Society ATS/ERS statement on respiratory muscle testing Am J Respir Crit Care Med 2002;166:518–624 References 195 FIELD EXERCISE TESTS Singh SJ, Puhan MA, Andrianopoulos V, et al An official systematic review of the European Respiratory Society/American Thoracic Society: Measurement properties of field walking tests in chronic respiratory disease Eur Respir J 2014;44:1447–78 CARDIOPULMONARY EXERCISE TESTS American College of Sports Medicine ACSM’s Guidelines for Exercise Testing and Prescription, 9th edition Baltimore, MD: Lippincott Williams and Wilkins, 2013 American Thoracic Society, American College of Chest Physicians ATS/ACCP Statement on cardiopulmonary exercise testing Am J Respir Crit Care Med 2003;167:211–77 Astrand P-O, Rodahl K, Dahl HA, Stromme SB Textbook of Work Physiology, 4th edition Champaign, IL: Human Kinetics, 2003 Balady GJ, Arena R, Sietsema K, et al Clinician’s guide to cardiopulmonary exercise testing in adults: A scientific statement from the American Heart Association Circulation 2010;122:191–225 Roca J, Whipp BJ, Agustí AGN, et al Clinical exercise testing with reference to lung diseases: indications, standardization and interpretation strategies ERS Task Force on Standardization of Clinical Exercise Testing Eur Respir J 1997;10:2662–89 Cooper CB, Storer TW Exercise Testing and Interpretation: A Practical Approach Cambridge: Cambridge University Press, 2004 ERS Task Force Recommendations on the use of exercise testing in clinical practice Eur Respir J 2007;29:185–209 Wasserman K, Hansen J, Sietsema K, et al Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications, 5th edition Baltimore, MD: Lippincott Williams and Wilkins, 2011 Index A Acid–base balance classification of, 140–141 evaluating compensation of acid–base disturbance, 141–143 evaluation of acid–base disorders, 143–144 measured indices/key definitions, 137–138 physiology of, 138–139 Acid–base disorders classification of, 140–141 evaluation of, 143–144 Acid–base disturbance, evaluating compensation of, 141–143 Airway diseases, 183–185 Airway investigations, diagnosis of asthma, 179 Airway obstruction fixed upper airway obstruction, 29 severity of, variable extrathoracic obstruction, 29–31 variable intrathoracic obstruction, 31 Airway resistance assessment of severity, 84 measurement of, 38 normal values, 76 oscillometry techniques, 79–84 patterns of abnormality, 76–78 plethysmography technique, 75–76 specific and clinical considerations, 84–85 test, physiology of, 74–75 Airway responsiveness, 35 interpretation of results, 37–40 test descriptions, 36–37 test physiology, 35–36 Alveolar CO2 concentration, 106 Alveolar gas, 128 Alveolar haemorrhage, 54 Alveolar Po2, 132 Alveolar ventilation, 105 Alveolar volume (VA), 46, 105 American Thoracic Society (ATS), Anaerobic threshold (AT), 160 Anaesthesia, 68 Anxiety, 113 Apnoeic respiration, 134–135 Arterial blood, 129–131 Arterial blood gases, 92 Arterial haemoglobin oxygen saturation (SpO2), 151 Arterialised capillary Po2, measurement of, 126–127 Arterial oxygenation, 115 197 198 Index Arterial partial pressure of carbon dioxide (Pco2), 95, 132 Arterial puncture, 125–126 Asthma, 42, 54, 183 assessment and management of, 11 clinical suspicion of, 178–179 peak flow variability in, 8–11 phenotypes, 43 B Besian coronary vein blood, 134 Blood oxygenation, Parameters relevant to, 116 Body box for short, 61, 62 Borg rating of perceived exertion, 147 Boyle’s law, 61 Breathing reserve, 164 Breathlessness scale, 153 Bronchiectasis, 184 Bronchiolitis, 184–185 Bronchoconstrictor, 37, 39 Bronchodilator, 36–38, 177 C Capillary blood, 126–127 Carbon monoxide poisoning, 122–123, 187 Carbon monoxide transfer coefficient (Kco), 45, 46–47, 180 Carboxyhaemoglobinaemia, 119 Cardiomyopathy, 168 Cardiopulmonary exercise testing (CPET) abnormality patterns, 165–169 assessment of severity, 169 key parameters, 156–158 test description/technique, 155, 159 Central nervous system disorders, 112 Chest wall deformity, 186 Chronic airflow limitation coexists, 93 Chronic obstructive pulmonary disease (COPD), 38, 110–111, 152, 183–184 Chronic pulmonary venous congestion, 187 Chronic respiratory failure, 135 ‘Church spire’ flow–volume loop, 25 Closing capacity, lung volume, 65 CO2, high production of, 112 Continuous positive airway pressure (CPAP), 69 COPD, see Chronic obstructive pulmonary disease Cor pulmonale, 99 Cough peak flow, 91–92, 100–101 CPAP, see Continuous positive airway pressure CPET, see Cardiopulmonary exercise testing D Dalton’s law, 128 Daytime hypercapnia, 92, 100 Diffuse loss of lung units, 52 Direct electromagnetic phrenic nerve stimulation, 91 Discrete loss of lung units, 51–52 Diurnal peak flow variability, 9–10 Index 199 DLco (diffusing capacity of lung for CO), 46 DO2 (oxygen delivery), 115 Dry air, humidification of, 128 Dynamic airway compression, 18–19 Dynamic lung volume tests, 57 Dyspnoea, algorithm for investigation of, 176 E Electronic peak flow devices, 10 Emphysema, 67 Endurance shuttle walk test (ESWT), 149, 151–152 ERV, see Expiratory reserve volume ESWT, see Endurance shuttle walk test European Respiratory Society (ERS), Exercise testing, 159 Exercise tolerance, 165 Exhaustion, 111–112 Expiratory reserve volume (ERV), 61 F FEF, see Forced expiratory flow FEV1, see Forced expiratory volume Field exercise tests description of tests, 148–149 field-walking test, choice of, 149–150 measurement indices, 147 normal values, 151–152 physiology of, 150 Fixed upper airway obstruction, 29, 185 Flow–volume curve (FVC), 177, 179–181 Flow–volume loop, 15, 177 defined, 13 large airways obstruction, 29–31 Forced expiratory flow (FEF), 22 Forced expiratory volume (FEV1), 16 lower limit of normality, 20–21 maximum value of, 18 obstructive spirometry, 23–25 reduction of, 27 Forced oscillometry technique (FOT), 79 Forced vital capacity (FVC), 16–18, 93–94 reduction of, 27 vs vital capacity, 23 FOT, see Forced oscillometry technique Fractional concentration of exhaled nitric oxide (FeNO), 41 physiology of test, 42–43 test description, 41–42 value in children and adults, 43–44 Functional residual capacity (FRC), 16, 57, 64–65, 68–70 FVC, see Flow–volume curve; Forced vital capacity G Gas transfer, 45 diffuse loss of lung units, 52 discrete loss of lung units, 51–52 incomplete lung expansion, 49–50 indices, 47 key definitions, 45–47 200 Index measurement of, 180 normal values, 48–49 pulmonary gas exchange, 48 pulmonary vascular disease, 53–54 test description, 47–48 Global Initiative for Asthma (GINA), 38 Guillain–Barré syndrome, 99 H Haemoglobinopathy, 119 Haemoglobin saturation, assessment of carbon monoxide poisoning, 122–123 measured indices, 115–116 normal values, 122 oxygen dissociation curve– physiology, 120–121 oxygen saturation, measurement of, 116–119 pulse oximetry, pros and cons of, 120 Heart rate (HR), 161 Helium dilution, 59–60 Humidification of dry air, 128 Hyperbaric chamber, 123 Hypercapnia causes of, 107–108, 109 chronic obstructive pulmonary disease, 110–111 exhaustion, 111–112 increased CO2 production, 112 obesity hypoventilation syndrome, 111 pitfall, 110 Hypopnoeas, 96, 97–98 Hypoventilation, 97 Hypoxaemia, 133–134 I ILD, see Interstitial lung disease Impulse oscillometry system (IOS), 79 Incomplete lung expansion, 49–50 Incremental shuttle walk test (ISWT), 149, 151 Inflatable balloon catheters, 91 Intensive therapy unit (ITU), 118 Interstitial lung disease (ILD), 54–55, 67, 180 Intrathoracic abnormality, patterns of large airways obstruction, 29–31 mixed obstructive/restrictive defect, 27–28 non-specific ventilatory defect, 28–29 obstructive spirometry, 23–25 restrictive spirometry, 25–27 IOS, see Impulse oscillometry system Ischaemic heart disease, 166–168 ISWT, see Incremental shuttle walk test ITU, see Intensive therapy unit L Large airway obstruction, 184 Long-term oxygen therapy (LTOT), 127 M Maximal expiratory pressure (MEP), 90, 94–95 Maximal inspiratory pressure (MIP), 90, 94–95, 100 Index 201 Nail varnish, 119 Nitric oxide (NO), 41, 42–43 Nitrogen washout, 61 Nocturnal hypoventilation, 99 Non-specific ventilatory defect, 28–29 Obstructive spirometry, 23–25 OHS, see Obesity hypoventilation syndrome Oscillometry techniques measured indices, 79–81 normal values, 82 patterns of abnormality, 82–84 test description, 79 Oxygenation, assessment of alveolar Po2 and arterial Pco2, 132 arterialised capillary Po2, measurement of, 126–127 normal values, 125 oxygen cascade, see Oxygen cascade partial pressure of arterial oxygen, measurement of, 125–126 specific clinical considerations, 133–135 Oxygen cascade, 127–128 arterial blood, 129–131 humidification of dry air, 128 tissue, 132 Oxygen dissociation curve, 120–121 Oxygen pulse, 161, 168–169 Oxygen saturation, measurement of, 116–119 Oxygen therapy, 110 Oxyhaemoglobin desaturation, 147 O P Obesity, 54, 68 Obesity hypoventilation syndrome (OHS), 111 Obstructive defects, 18, 21–22 Obstructive lung disease, 55–56, 67 PAH, see Pulmonary arterial hypertension Partial pressure of arterial oxygen (Pao2), measurement of, 120, 125–126, 129 Maximum expiratory flows, 18–20 Mechanical ventilatory support, 68 MEP, see Maximal expiratory pressure Metabolic acidosis, 112, 140–141 Metabolic compensation, for respiratory disorder, 142 Metabolic disorder, 140–141, 142 Methacholine challenge test, 39 Methaemoglobinaemia, 119 Mid-expiratory flow, 22 Minute volume of ventilation (V˙E), 105 MIP, see Maximal inspiratory pressure Mixed obstructive/restrictive defect, 27–28 Muscle strength clinical interpretation of tests, 93–95 radiological assessment of, 92–93 Muscle weakness, 186 Myocardial infarction, 15 N 202 Index Peak expiratory flow (PEF) assessment and management of asthma, 11 normal values for, pitfalls, 7, 12 variability in diagnosis asthma, 8–11 Peak O2 pulse, 164 PEEP, see Positive end-expiratory pressure PEF, see Peak expiratory flow Pharmacological challenge tests, 37, 38–40 Physiological responses anaerobic threshold, 160 electrocardiogram, 164 heart rate and oxygen pulse, 161 systemic systolic blood pressure, 159 ventilation, 159–160, 162 ventilatory efficiency, 163–164 Plethysmography technique, 75–76 Pleural disease, 185 Positive end-expiratory pressure (PEEP), 69 Post-pulmonary resection surgery, 186 Progressive myopathy, 99 Pulmonary arterial hypertension (PAH), 152, 187 Pulmonary blood volume, 54 Pulmonary capillaries, destruction of, 153 Pulmonary emphysema, 52 Pulmonary function abnormalities airway diseases, 183–185 interstitial lung disease, 185–188 Pulmonary function tests asthma, clinical suspicion of, 178–179 flow–volume curve (FVC) reduce, 179–181 obstruction, evidence of, 175–178 transfer factor for carbon monoxide (TLCO) reduce, 181 Pulmonary gas exchange, 48 Pulmonary resection, 52 Pulmonary vascular disease, 53–54, 168–169, 187 Pulse oximetry, 117–120, 123 R Rapid eye movement (REM) sleep, 95 Recurrent pulmonary emboli, 187 REM sleep, see Rapid eye movement sleep Residual volume (RV), 17, 64 Respiratory acidosis, 140, 142 Respiratory muscle strength arterial blood gases, 92 clinical interpretation of tests of, 93–95 cough peak flow, 91–92 evaluation of, 180–181 maximal inspiratory pressure, 89 radiological assessment, 92–93 sleep, ventilatory failure, and vital capacity, 95–99 sniff nasal inspiratory pressure, 89–90 sniff trans-diaphragmatic pressure, 91 upright and supine vital capacity, 87–89 Index 203 Resting tidal ventilation, 75 Restrictive defects, 16–18, 185–188 Restrictive spirometry normal-shaped trace, 26 respiratory muscle weakness, 26–27 ‘Wizard hat’ flow–volume loop, 25–26 Reversibility testing, 36, 37–38, 84 RV, see Residual volume S SaO2 (arterial haemoglobin oxygen saturation), 116–117 Scottish Intercollegiate Guidelines Network (SIGN), 37–38 Single-breath method, 48 Six-minute walk test (6MWT), 148–149, 151 Small airways, 84 Sniff nasal inspiratory pressure, 90–91, 94, 100 Sniff trans-diaphragmatic pressure, 91 Spinal cord injury, 101 Spirometry, 35 contraindications to, 15–16 defined, 13 intrathoracic abnormality, see Intrathoracic abnormality, patterns of maximum expiratory flows, 18–20 mid-expiratory flow, 22 normal values, 20–21 parameters measured at, 14–15 physiology of tests, 16–18 severity of obstruction, 21–22 Standard bicarbonate, 137–138 Standard deviations (SDs), 1–3 Static lung volumes lung volumes, physiology of, 64–65 measured indices, 57–58 normal values, 65–66 patterns of abnormality, 66–68 specific considerations, 68–70 test descriptions, 59–64 Supine vital capacity, 87–89 Svo2 (mixed venous oxygen saturation), 115 Systemic blood pressure, 159, 164 T Tissue, 132 Total lung capacity (TLC), 17–18, 57, 64 Transfer factor for carbon monoxide (TLco), 45–46, 49, 178 U Upright vital capacity, 87–89 V Variable extrathoracic obstruction, 29–31 Variable intrathoracic obstruction, 31, 32 VC, see Vital capacity Venous admixture, 134 Venous blood gases, 109 Ventilation, 105 causes of hypercapnia, 109–112 causes of low Pco2, 112–113 efficiency, 163–164 204 Index measurement of venous blood gases, 109 mechanical support, 68 normal values, 108 physiology of, relation to CO2, 105–108 Vital capacity (VC), 57 vs forced vital capacity, 23 vs total lung capacity, 67 V ˙o2 (rate of oxygen), 115 Volition, 84 W Whole-body plethysmography, 61–63 ‘Wizard hat’flow–volume loop, 26 .. .MAKING SENSE of Lung Function Tests Second edition A hands-on guide MAKING SENSE of Lung Function Tests Second edition A hands-on guide Jonathan... K CO Test description Physiology of gas exchange Normal values Patterns of abnormality Incomplete lung expansion Discrete loss of lung units Diffuse loss of lung units 23 23 23 25 27 27 28 29... plethysmography Comparison of methods Physiology of lung volumes Total lung capacity Residual volume Functional residual capacity Closing capacity Normal values Patterns of abnormality Relationship