Usage of Pulmonary Function Tests in Clinic Except Spirometry Diffusion Capacity

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Usage of Pulmonary Function Usage of Pulmonary Function Tests in Clinic Except Tests in Clinic Except

Spirometry Diffusion CapacitySpirometry Diffusion Capacity

Prof.Dr.Birsen MUTLUProf.Dr.Birsen MUTLU

I.U.Cerrahpasa Medical FacultyI.U.Cerrahpasa Medical Faculty Department of Pulmonary DiseasesDepartment of Pulmonary Diseases

22

Pulmonary Function Tests Application FieldPulmonary Function Tests Application Field

1-Diagnosis and treatment of Lung and 1-Diagnosis and treatment of Lung and Heart diseases Heart diseases

2-Preoperative evaluation2-Preoperative evaluation3-Evaluation of disability3-Evaluation of disability4-Epidemiologic studies for the 4-Epidemiologic studies for the

evaluation of industrial diseasesevaluation of industrial diseases5-Simple determination of disease 5-Simple determination of disease

incidence in a given population incidence in a given population

33

-Alveols -Alveols

-Airways (Ventilation)-Airways (Ventilation)

-Capillary network (perfusion)-Capillary network (perfusion)

44

-Ventilation-Ventilation

-Distribution-Distribution

-Diffusion-Diffusion

-Perfusion-Perfusion

55

Pulmonary Function TestsPulmonary Function Tests

A- Airway functionA- Airway function 1.Simple spirometry1.Simple spirometry Vital capacity(VC),expiratory reserve volume Vital capacity(VC),expiratory reserve volume (ERV), (ERV),

inspiratory capacity (IC)inspiratory capacity (IC)

2.Forced vital capacity maneuver2.Forced vital capacity maneuver a-FVC,FEV1,FEF,PEFa-FVC,FEV1,FEF,PEF (1)Prebronchodilator and postbronchodilator(1)Prebronchodilator and postbronchodilator (2)Prebronchochallenge and (2)Prebronchochallenge and

postbronchochallengepostbronchochallenge

b-MEFV curves,Vmaxb-MEFV curves,Vmaxxx

(1)Prebronchodilator and Postbronchodilator(1)Prebronchodilator and Postbronchodilator (2)Prebronchochallenge and (2)Prebronchochallenge and

postbronchochallengepostbronchochallenge

66

3.Maximal voluntary ventilation3.Maximal voluntary ventilation (MVV)(MVV)

4.Maximal inspiratory/expiratory 4.Maximal inspiratory/expiratory pressures (MIP/MEP)pressures (MIP/MEP)

5.Airway resistance (Raw) and 5.Airway resistance (Raw) and Compliance (C)Compliance (C)

77

B-Lung volumes and ventilationB-Lung volumes and ventilation 1.Functional residual capacity (FRC)1.Functional residual capacity (FRC) a.Open-circuit (N2 washout)a.Open-circuit (N2 washout) b.Closed-circuit/rebreathing ([He dilution)b.Closed-circuit/rebreathing ([He dilution) c.Thoracic gas volume (Vc.Thoracic gas volume (VTGTG)) 2.Total lung capacity (TLC),residual 2.Total lung capacity (TLC),residual

volume (RV),RV/TLC ratiovolume (RV),RV/TLC ratio 3.Minute ventilation,alveolar ventilation and 3.Minute ventilation,alveolar ventilation and

dead space dead space 4.Distribution of ventilation4.Distribution of ventilation a.Multiple-breath N2a.Multiple-breath N2 b.He equilibrationb.He equilibration c.Single-breath techniquesc.Single-breath techniques

Pulmonary Function TestsPulmonary Function Tests

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Pulmonary Function TestsPulmonary Function Tests

C- Diffusion capacity testsC- Diffusion capacity tests

1. Single-breath(breath holding)1. Single-breath(breath holding)

2. Steady state2. Steady state

3. Other techniques3. Other techniques

99

D-Blood gases and gas exchange testsD-Blood gases and gas exchange tests

1.Blood gas analysis 1.Blood gas analysis

2. Pulse oximetry2. Pulse oximetry

3. Capnography3. Capnography

Pulmonary Function TestsPulmonary Function Tests

1010

E- Cardiopulmonary exercise testsE- Cardiopulmonary exercise tests

1. Simple noninvasive tests1. Simple noninvasive tests

2. Tests with exhaled gas analysis2. Tests with exhaled gas analysis

3. Tests with blood gas analysis3. Tests with blood gas analysis F- F- Metabolic measurementsMetabolic measurements

Pulmonary Function TestsPulmonary Function Tests

1111

DIFFUSIONDIFFUSION

This is an electrochemical event This is an electrochemical event between gas and liquid. Occurs due between gas and liquid. Occurs due to the partial pressure difference of to the partial pressure difference of the gases.the gases.

1212

DIFFUSION CAPACITYDIFFUSION CAPACITY

Amount of gas (mL) passed through Amount of gas (mL) passed through the capillary membrane in a given the capillary membrane in a given time(1min) and in a given pressure time(1min) and in a given pressure difference (1mmHg) difference (1mmHg) (mL/min/mmHg)(mL/min/mmHg)

1313

DIFFUSION VELOCITYDIFFUSION VELOCITY

V=A.k.α.(PV=A.k.α.(P11--PP22))

hhV=Diffusion velocity within a given timeV=Diffusion velocity within a given timeA=Diffusion surface areaA=Diffusion surface areak=diffusion constantk=diffusion constantα=gas solubilityα=gas solubilityPP1-1-PP22= Partial pressure difference of two = Partial pressure difference of two

environment that the diffusion takes environment that the diffusion takes place in.place in.

h=membrane thicknessh=membrane thickness

1414

Factors that effect diffusion velocityFactors that effect diffusion velocity

-k (diffusion constant)-k (diffusion constant)-Α (solubility)-Α (solubility)-Viscosity of diffusion milieu-Viscosity of diffusion milieu

Air diffusion velocity>water diffusionAir diffusion velocity>water diffusion velocityvelocity

**Tissue diffusion velocity Tissue diffusion velocity == fluid diffusion fluid diffusion velocityvelocity

**Exclusion: Exclusion:

Erythrocyte hb concentration viscosity Erythrocyte hb concentration viscosity diffusion diffusion velocityvelocity

1515

-CO is the standart gas that used in -CO is the standart gas that used in diffusion measurementsdiffusion measurements

-It has high Hgb. affinity-It has high Hgb. affinity

-The only factor that limits CO diffusion is -The only factor that limits CO diffusion is alveolocapillary membranealveolocapillary membrane

1616

ERS (1993) TERS (1993) TLLCO:Transfer factorCO:Transfer factor

ATS (1995) DATS (1995) DLLCO:Diffusion capacityCO:Diffusion capacity

DDLLCO=mL/dak/mmHgCO=mL/dak/mmHg

TTLLCO=mmoL/dak/kPaCO=mmoL/dak/kPa

DDLLCO/TCO/TLLCO =3:1CO =3:1

DDLLCO x O.33=TLCOCO x O.33=TLCO

1717

Diffusion ventilation ratioDiffusion ventilation ratio

ERS TERS TLLCO/VA (=KCO)Transfer CO/VA (=KCO)Transfer coefficient coefficient

ATS DATS DLLCO/VACO/VA

(mL/dak/mmHg)(mL/dak/mmHg)

1818

Methods used in diffusion Methods used in diffusion measurementmeasurement

1-Single-breath holding1-Single-breath holding

2-Single expiration2-Single expiration

3-Rebreathing3-Rebreathing

4-Steady state4-Steady state

5-Riley-Lilienthal5-Riley-Lilienthal

6-V6-VAA/Q/Q

7-Single breath oxygen holding7-Single breath oxygen holding

1919

Resting DResting DLLCO:25 mLCO/min/mmHgCO:25 mLCO/min/mmHg

%81-140 (predicted)=>normal%81-140 (predicted)=>normal

%61-80 (predicted)=>mild decrease%61-80 (predicted)=>mild decrease

%41-60 (predicted)=>moderate%41-60 (predicted)=>moderate

<%40 (predected)=>significantly <%40 (predected)=>significantly decreased decreased

2020

Factors that effect DFactors that effect DLLCO CO measurementmeasurement

1-Age,height,body surface area1-Age,height,body surface area

2-Cigarette smoking2-Cigarette smoking

3-Hemoglobin level3-Hemoglobin level

4-Body position and exercise4-Body position and exercise

5-Lung volumes5-Lung volumes

6-Inspiration and expiration maneuver6-Inspiration and expiration maneuver

2121

Factors that effect DFactors that effect DLLCO CO measurementmeasurement

7-Altitude7-Altitude

8-Oxygen concentration8-Oxygen concentration

9-Diurnal distribution9-Diurnal distribution

10-Menstrual cycle10-Menstrual cycle

11-Drinking alcohol11-Drinking alcohol

12-Sex and marital status12-Sex and marital status

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Age, height, body surface areaAge, height, body surface area

in children Din children DLLCOCO**AgeAge in elderly Din elderly DLLCOCO

** Body surface area, Body surface area, height, height, DLCO DLCOmuscle structuremuscle structure

**Weight has no effectWeight has no effect

2323

Cigarette smokingCigarette smoking

Chronic cigarette smoking DChronic cigarette smoking DLLCO and KCOCO and KCO

Acute smoking,Acute smoking,Occupational CO exposure alveolar CO pressureOccupational CO exposure alveolar CO pressureFrequently repeated testFrequently repeated test

**Decreased measurement due to smoking is Decreased measurement due to smoking is maksimum 10%.maksimum 10%.

**Must stop smoking at least 24 hours earlierMust stop smoking at least 24 hours earlier**Modification must be done in frequent smokersModification must be done in frequent smokers

2424

Hemoglobin levelHemoglobin level

Hb DHb DLLCO CO

Hb DHb DLLCOCO

-1 gram change in Hgb will change D-1 gram change in Hgb will change DLLCO 7%CO 7%

-Measured D-Measured DLLCO value: Standardized due to CO value: Standardized due to Hgb:14.6g/dLHgb:14.6g/dL

-D-DLLCO must be corrected due to changes in CO must be corrected due to changes in Hgb Hgb

2525

Body position and exerciseBody position and exercise

-In dawnward position-In dawnward position

the difference the difference

is %5-30is %5-30

-In upright position-In upright position

**Reason:Reason:During positional changes pulmonary blood volumeDuring positional changes pulmonary blood volume

-During exercise -During exercise

**In active persons DIn active persons DLLCO and DCO and DLLCO/VCO/VAA

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Lung VolumesLung Volumes

Volumes DVolumes DLLCO CO

To detect actual diffusion loss ;To detect actual diffusion loss ;

DDLLCO/VCO/VAA (KCO) must be (KCO) must be usedused

2727

Inspiration and Expiration Inspiration and Expiration ManeuversManeuvers

ValsalvaValsalva

maneuversmaneuvers

MullerMuller

effect effect

intrathoracicintrathoracic

pressurepressure

2828

AltitudeAltitude

Altitude Altitude FFIOIO22 D DLLCOCO **Correction may be necessaryCorrection may be necessary

Oxygen concentrationOxygen concentration

There is negative correlation between PThere is negative correlation between PAAOO2 2

and Dand DLLCOCO * * No ONo O2 2 supplemantationsupplemantation during testduring test

2929

Diurnal alterationDiurnal alteration

DDLLCO reaches Peak level in the morningCO reaches Peak level in the morning **During daytime During daytime progressively progressively 1-2%) per hour1-2%) per hour

Menstrual cycle and parityMenstrual cycle and parity

-~13% change during cycle -~13% change during cycle (Changes are due to Hgb effect)(Changes are due to Hgb effect)

-No significant change during parity-No significant change during parity

3030

Alcohol drinkingAlcohol drinking

15-30ml 95% alcohol will decrease 15-30ml 95% alcohol will decrease DDLLCO 15% after 90 minutesCO 15% after 90 minutes

Sex and ethnic conditionSex and ethnic condition

DDLLCO in men > womenCO in men > women DDLLCO whites > blacksCO whites > blacks

3131

CLINICAL USAGECLINICAL USAGEDecrease in DLCO ASSOCIATED WITH:Decrease in DLCO ASSOCIATED WITH:1-Obstructive lung diseases1-Obstructive lung diseases EmphysemaEmphysema Cystic fibrosisCystic fibrosis2-Parenchymal diseases2-Parenchymal diseases Interstitial pneumoniaInterstitial pneumonia Extrinsic allergic alveolitisExtrinsic allergic alveolitis Viral pneumoniaViral pneumonia Chronic interstitial fibrosis (silicos) Chronic interstitial fibrosis (silicos) Bronchioalveolar lung cancerBronchioalveolar lung cancer Drug reaction(bleomycin,nitrofurantoin)Drug reaction(bleomycin,nitrofurantoin) Alveolar proteinous and microlithyasisAlveolar proteinous and microlithyasis LymphangioleiomyomatosisLymphangioleiomyomatosis

3232

3-Systemic diseases effecting lung3-Systemic diseases effecting lung -Sarcoidosis-Sarcoidosis -Disseminated tuberculosis-Disseminated tuberculosis -Progressive systemic sclerosis-Progressive systemic sclerosis -RA-RA -SLE-SLE -Mixed Connective Tissue Diseases-Mixed Connective Tissue Diseases -Dermatomyositis-Polymyositis-Dermatomyositis-Polymyositis -Wegener granulomatosis-Wegener granulomatosis -Inflammatory intestinal diseases-Inflammatory intestinal diseases

3333

4-Cardiopulmonary diseases4-Cardiopulmonary diseases -PPH -PPH -TEAH-TEAH -Lung edema-Lung edema -Mitral stenosis-Mitral stenosis -Acute MI-Acute MI5-Othere causes5-Othere causes -Anemia -Anemia -CRF -CRF -Chronic hemodialysis -Chronic hemodialysis -BOOP-BOOP -Cocaine,marijuana-Cocaine,marijuana -Acute and chronic alcohol drinking-Acute and chronic alcohol drinking -Cigarette smoking -Cigarette smoking

3434

FACTORS DECREASING DLCO WHICH ARE FACTORS DECREASING DLCO WHICH ARE INDEPENDENT FROM OTHER VENTILATORY INDEPENDENT FROM OTHER VENTILATORY PARAMETERSPARAMETERS

-Interstitial diseases that don’t effect -Interstitial diseases that don’t effect airflowairflow

-Pulmonary venoocclusive diseases-Pulmonary venoocclusive diseases

-Inflamatory diseases -Inflamatory diseases

-Microembolism-Microembolism

3535

DLCO/VA:N -restrictionDLCO/VA:N -restriction

DLCODLCO -parenchymal -parenchymal changeschanges

DLCO/VA: -obstruction DLCO/VA: -obstruction

-dead space-dead space

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InitiallyInitially (upper field blood flow (upper field blood flow

cardiac output )cardiac output )

After progressionAfter progression:: ((V/Q equilibrium disturb)V/Q equilibrium disturb)

ASTHMAASTHMA

3737

CONGESTIVE HEARTH FAILURECONGESTIVE HEARTH FAILURE

Initially Initially (dilatation of pulmonary (dilatation of pulmonary

vessels)vessels)

After lung edemaAfter lung edema

3838

-Resection surgery D-Resection surgery DLLCOCO

-VAC -VAC

DDLLCOCO

-Bullectomy-Bullectomy

3939

DISEASES INCREASING DDISEASES INCREASING DLLCOCO

1-Diseases involve polystemia1-Diseases involve polystemia2-Alveolar haemorhage:Good Pasture 2-Alveolar haemorhage:Good Pasture

syndromesyndrome3-Increased pulmonary blood volume:left-3-Increased pulmonary blood volume:left-

right intracardiac shuntsright intracardiac shunts4-In Asthma, generally 4-In Asthma, generally N N

During attackDuring attack

4040

Diseases not effecting DDiseases not effecting DLLCOCO

1-Chest diseases1-Chest diseases

2-Pleura2-Pleura

3-Asthma3-Asthma

4-Bronchitis4-Bronchitis

5-Localised pulmonary lesions5-Localised pulmonary lesions

6-Neurofibrotic pneumoconiosis6-Neurofibrotic pneumoconiosis

4141

DDLLCOCO

IncreasedIncreased DecreasedDecreased

-ALVEOLAR-ALVEOLAR HAEMORRHAGEHAEMORRHAGE-POLYSTEMIA-POLYSTEMIA- DECREASE IN - DECREASE IN PULMONARY PULMONARY BLOOD VOLUMEBLOOD VOLUME

DDLLCO/VCO/VAA

NORMALNORMAL DECREASEDDECREASED

-DECREASED-DECREASEDLUNG VOLUMELUNG VOLUME-PARENCHYMAL-PARENCHYMALDESTRUCTIONDESTRUCTION

-OBSTRUCTION-OBSTRUCTION-INCREASED -INCREASED DEAD SPACEDEAD SPACE

4242

Indications of Diffusion CapacityIndications of Diffusion Capacity

1-Evaluation of parenchymal lung diseases1-Evaluation of parenchymal lung diseases

-organic and inorganic dust-organic and inorganic dust-drugs and lung-drugs and lung

2-Systemic diseases involve lung2-Systemic diseases involve lung

-RA-RA-Sarcoidosis-Sarcoidosis-SLE-SLE-Systemic sclerosis-Systemic sclerosis-Mixed connective tissue diseases-Mixed connective tissue diseases

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3-Obstructive lung diseases3-Obstructive lung diseases

-Differential diagnosis(asthma- -Differential diagnosis(asthma- COPD) COPD)

-Disease progression follow-up -Disease progression follow-up

-Calculation of desaturation -Calculation of desaturation during during exercise in COPD exercise in COPD

4-Cardiovascular diseases4-Cardiovascular diseases

-PPH-PPH

-TELD-TELD

-Lung edema-Lung edema

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5-Quantification of disability in interstitial 5-Quantification of disability in interstitial lung diseaseslung diseases

6-Detection of factors that increase D6-Detection of factors that increase DLLCOCO-polystemia-polystemia-pulmonary haemorrhage-pulmonary haemorrhage-left-right intracardiac shunt-left-right intracardiac shunt

7-Prediction of postoperative functional 7-Prediction of postoperative functional condition for preoperative evaluation condition for preoperative evaluation

4545

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

4646

PV disease

Thoracic cavity and NM diseases

ILD ve Int pneumonia

Asthma and chronic bronchitis

COPD and Emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

4747

ISPIROMETRY + FLOW-VOLUME CURVE

4848

4949

LUNG VOLUMES

5050

4.134.13

DIFFUSSION CAPACITY

5151

DDLLCOCO

SEVERITY SEVERITY DLCO % predDLCO % pred

MILD MILD >>% 60 % 60 andand <<LLNLLN

MODERATEMODERATE % 59-40 % 59-40

SEVERESEVERE <<% 40% 40

ATS/ERS AFT Standardisation ERJ 2005;26:153-161, 319-338, 511-522,720-735,

948-968

5252

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

5353

5454

PFT NORMAL, DPFT NORMAL, DLLCO DECREASEDCO DECREASED

SclerodermaScleroderma

Primary pulmonary hypertensionPrimary pulmonary hypertension

PULMONARY EMBOLISMPULMONARY EMBOLISM

VasculitisVasculitis

5555

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

5656

SPIROMETRYSPIROMETRY

5757

5858

LUNG VOLUMES

5959

4.64

DIFFUSIONDIFFUSION

6060

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

6161

SPIROMETRYSPIROMETRY

6262

FL

6363

4.67

DIFFUSIONDIFFUSION

6464

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

6565

FEV1/FVC %98 FVC 1.98 L %57 FEV1 1.70 L %58 TLC 3.35L %71 DLCO 22 mL/dak/mmHg %96

6666

PV disease

Thoracic cavity and NM disease

ILD and Int pneumonia

Asthma and chronic

bronchitis

COPD and emphysema

Normal

YES

YES

YES

YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO NO

Restriction Obstruction Mixed defect

Normal ?

FEV1/FVC>%70

FEV1>%80 FEV1>%80

TLC TLC

DLCO DLCO DLCO

1

2

4

3Flow-Volume

curve

5

6767

Diffusion TestDiffusion Test

-Correct indication-Correct indication

-Acceptable method that fits the -Acceptable method that fits the desired acceptability criterias desired acceptability criterias

-Correct comment-Correct comment