Pocket Guide to Lung Function Tests - sample chapter

Chapter 1
Spirometry
S
pirometry is a measure of airflow and lung volumes during a
forced expiratory manoeuvre from full inspiration. It is the sim-
plest of all respiratory function tests. It is fundamental to the
diagnosis and assessment of airways disease and is often the only nec-
essary test. The measurements made during spirometry are sometimes
referred to as ‘dynamic lung volumes’.
Correct interpretation of spirometry requires that it be performed
correctly (see ATS/ERS criteria for acceptable and repeatable
Spirometry). To obtain an accurate recording the subject should be
told to:
• sit up straight
• get a good seal around the mouthpiece of the spirometer
• rapidly inhale maximally (‘breathe in all the way’)
• without delay, blow out as hard and as fast as possible (‘blast out’)
• continue to exhale (‘keep going … keep going’) until the patient
can blow no more. In practice this is when less than 25 mL has
been exhaled over 1 second. Expiration should continue for at
least 6 seconds (3 seconds in children under 10 years old) and up
to 15 seconds if necessary (some patients will find this exhausting
and prolonged manoeuvres should be used with caution)
Manoeuvres are repeated until at least three technically acceptable
manoeuvres (no coughs, air leaks, false starts) are completed. If
required, more tests should be done to try to meet repeatability crite-
ria (no more than 8 attempts in total).
Ch 1 Hancox 6/10/05 10:38 AM Page 1

The two largest FEV1 measurements and the two largest FVC
measurements should be within 150 mL of each other. The largest
of each of these (not necessarily from the same manoeuvre) should
be reported.
Efforts interrupted by coughing should be discarded (some
patients cough only towards the end of the manoeuvre—this may not
significantly alter the FEV1 or FVC).
Poor measurement technique can produce results which mimic
disease patterns. Common errors occur when the patient fails to
inhale fully before the test, stops blowing too early (apparent restric-
tive defect), or doesn’t blow out hard enough (apparent obstructive
defect). Some patients are unable to perform repeatable spirometry—
this may be useful information in itself. It is recommended that no
more than eight blows are attempted at any one time. If reproducible
results are not obtained, the highest of the technically acceptable
results should be reported with a comment that repeatability criteria
were not met.
Most modern spirometers can produce flow-volume loops.
Inspection of the flow-volume loop, if available, will help to decide
whether the measurement was done correctly as well as confirming
the presence of an abnormality (see Chapter 2).
Abnormal spirometry may be masked by treatment.
Bronchodilator and other relevant drugs should be withheld for at
least the expected duration of action of the drug. If this is not
possible, the fact should be recorded and the results interpreted
accordingly.
There are several types of spirometer. Many are designed for use
outside of the lung function laboratory and some are intended for
home use by the patient. All types are acceptable, provided that they
meet or exceed the minimum standards of the American Thoracic
Society and European Respiratory Society (see Types of spirometer,
p. 4).
FEV1, FVC and FER
Spirometry provides three basic measurements:
• the forced vital capacity (FVC)
• the forced expiratory volume in one second (FEV1)
• the ratio of the FEV1/FVC (the forced expiratory ratio FER,
also known as the FEV1%).
2 McGraw-Hill’s pocket guide to lung function tests

Spirometry 3
AMERICAN THORACIC SOCIETY/EUROPEAN RESPIRATORY
SOCIETY CRITERIA FOR ACCEPTABLE AND REPRODUCIBLE
SPIROMETRY
The ATS and ERS have recently produced joint guidelines for performing
spirometry. Differences from earlier guidelines are minor. Many spirometers
have built-in warnings if the acceptability criteria are not met. Some patients
cannot produce acceptable and repeatable manoeuvres and you should
exercise clinical judgement whether to accept an imperfect result that
provides some information or discard the results of all the manoeuvres and
get no information.
ACCEPTABILITY CRITERIA
• Free from artefacts (such as cough or glottis closure early in expiration)
• Free from leaks
• Good starts
— extrapolation back from the peak flow (which is the steepest part of
the spirogram curve) produces a theoretical start time from which
the measurements should be timed. This ‘new time zero’ should
occur within 5% of the FVC or within 150 mL
• Acceptable exhalation
— Adults: at least 6 seconds of exhalation and a plateau in the volume
curve (plateau = no detectable change in volume over 1 second)
— Children aged under 10: at least 3 seconds of exhalation and a
plateau in the volume curve
REPEATABILITY CRITERIA
• Three acceptable manoeuvres (meeting above criteria)
• The two largest FVC measurements within 150mL of each other
• The two largest FEV1 measurements within 150mL of each other
When both acceptability and repeatability criteria are met, the test can
be concluded. Up to 8 manoeuvres should be performed until the criteria
are met or the patient is unable to continue. As a minimum, the three
satisfactory (or best) manoeuvres should be saved.
All three are needed to interpret spirometry. A normal spirogram
is shown in Figure 1.1 (p. 5). This plots the total volume exhaled
against time. The trace becomes flat after about 3–4 seconds because
the total volume of air which can be exhaled (the FVC) is expelled
within this time. Approximately 80% of this volume (slightly lower

in older people) is exhaled within 1 second, so the FEV1/FVC ratio is
normally 0.7–0.8 or 70–80%.
Spirometry can demonstrate two basic patterns of disorder—
obstructive and restrictive.
Obstructive pattern
In obstructive disorders (for example, asthma or chronic obstructive
pulmonary disease), airflow is reduced because the airways narrow
and the FEV1 is reduced (Fig. 1.2). The spirogram may continue to
TYPES OF SPIROMETER
There are numerous spirometer devices available, and they fall into two
basic categories: those measuring a change in volume, or measuring flow.
VOLUME-DISPLACEMENT SPIROMETERS
These include water-sealed devices (the original method invented by
Hutchinson in the mid-1800s) in which the volume displaced is collected in
a bell sealed by a water reservoir. Others may have a bellows device or
rolling-seal cylinder/piston devices. The volume displaced is recorded and
the flow is calculated as the volume change over time. The spirogram can be
drawn by a pen (indicating volume) on moving graph paper (indicating
time). More modern devices can include computer analysis of the spirogram
curve. The simplicity and accuracy of these devices make them very reliable.
However, each is bulky and impractical for home use.
FLOW-SENSING DEVICES
Flow-sensing spirometers measure airflow, and integrate this to determine
volume. Several methods are used to detect the flow. These include
pneumotachographs, in which a resistive element is placed in the airflow.
The small pressure difference on either side of the element is related to the
airflow. Heated wire devices use the airflow to cool a heated wire. The flow
is calculated from the current required to maintain the wire temperature.
Rotating vane devices place a small turbine in the airstream; the turbine
spins at a rate according to the flow. Ultrasound devices measure the change
in ultrasound transmission time with airflow.
Regardless of the type of device, it should be checked at regular
intervals using a calibrated syringe (either 1 L or 3 L).

Spirometry 5
Time (seconds)
FVC
FEV1
Volume
0 1 2 3 4 5 6
Figure 1.1 Normal spirogram
Note that approximately 80% of the total volume is exhaled in the first 1 second
(the FEV1) and that the curve has reached a plateau by 6 seconds.
Time (seconds)
FVC
FEV1
0 1 2 3 4 5 6
Volume
Figure 1.2 Spirogram showing airways obstruction
Both the FEV1 and the FVC may be reduced, but the FEV1 is reduced to a
greater extent. The FEV1/FVC ratio is therefore low. In this patient, the forced
expiratory time is prolonged and a convincing plateau has not been reached by
6 seconds. Ideally, the patient should continue to blow until a plateau has
been reached.

rise for more than 6 seconds because the lungs take longer to empty.
The FVC may also be reduced (because gas is trapped behind
obstructed bronchi) but to a lesser extent than the FEV1. Thus the
cardinal feature of an obstructive defect is a reduction in the
FEV1/FVC ratio.
Although the FEV1/FVC ratio is very useful in diagnosing airflow
obstruction, the absolute value of the FEV1 is the best measure of
severity. In general, a reduction in FEV1 to 60–80% of predicted indi-
cates mild, 40–60% moderate and less than 40% severe obstruction.*
Patients with an FEV1 of less than 1 litre are likely to be limited by
dyspnoea. If the FEV1 is less than 0.5 litres, the patient is likely to be
breathless at rest and in respiratory failure. Conversely, a patient with
an FEV1 of more than 2 litres is unlikely to be short of breath due to
airways disease except on vigorous exertion.
Restrictive pattern
Restrictive disorders can be caused by disease of the lung parenchyma
(such as interstitial lung fibrosis) or chest wall disease (such as
kyphoscoliosis). These prevent full expansion of the lungs and
therefore the vital capacity (VC or FVC) is reduced. Airflow may be
normal or even increased because the stiffness of fibrotic lungs increas-
es the expiratory pressure. Thus although the absolute value of the
FEV1 may be reduced, the FEV1/FVC ratio is normal or high (Fig. 1.3).
A restrictive pattern on spirometry can be mimicked by a poor
technique. Often the FVC is underestimated because the patient stops
blowing too early. This will produce a high FEV1/FVC ratio (Fig. 1.4).
It is important to check that the spirometry was done correctly. Be
cautious about diagnosing a restrictive disorder on spirometry alone,
particularly if the FEV1 is in the normal range. Clinical correlation is
necessary and more detailed lung function tests are indicated. Ideally,
measurement of the total lung capacity (TLC) should be used to
confirm the diagnosis (see Chapter 4).
* There are several different ways to classify the severity of obstruction. For
example, the GOLD classification of chronic obstructive pulmonary disease is
based on post-bronchodilator spirometry. For patients with an FEV1/FVC ratio
<70%, mild is FEV1 ≥80%, moderate is FEV1 = 30–80% and severe is FEV1
<30%. (R. A. Pauwels, A. S. Buist, P. M. A. Calverley et al., ‘Global strategy for
the diagnosis, management and prevention of chronic obstructive pulmonary
disease’, American Journal of Respiratory and Critical Care Medicine, 2001,
163, pp. 1256–76.)

Spirometry 7
Figure 1.3 Spirogram showing a restrictive disorder
Both the FEV1 and FVC may be reduced, but the FVC is reduced to the same or
greater extent than the FEV1. In this case the FEV1/FVC ratio is high. The
plateau to the curve occurs early.
Time (seconds)
FVC
FEV1
0 1 2 3 4 5 6
Volume
Time (seconds)
FVC
FEV1
0 1 2 3 4 5 6
Volume
Figure 1.4 Inadequate technique mimicking a restrictive disorder
The patient stopped blowing too soon. The FVC is underestimated and the
FEV1/FVC ratio appears high, giving the impression of a restrictive disorder.

Time (seconds)
0 1 2 3 4 5 6
FVC
Volume
25%
75%
Slope = FEF25–75%
Figure 1.5 FEF25–75%
Other measurements of forced expiratory flow
Some spirometers will also provide other results, such as the
FEF25–75%. This is the forced expiratory flow between 25% and 75%
of the FVC (also called the maximum mid-expiratory flow, MMEF).
This is the slope between the points on the spirogram shown in Figure
1.5. This represents the airflow in the medium and small airways. It is
a sensitive but less reliable indicator of airflow obstruction than the
FEV1. It may indicate mild airways disease (for example, in an asth-
matic who is currently stable) but has a wide range of normal values,
and should be interpreted with caution if it is the sole abnormality.
Similar measurements include the FEF at fixed points of the
spirogram. For example, FEF25%, FEF50% and FEF75% are the flows
recorded at 25%, 50% and 75% of the FVC respectively.
In addition to the FEV1, the forced expiratory volume in other time
intervals may be recorded. The FEV0.5 or the FEV0.75 are sometimes
used in children in whom the normal FEV1/FVC ratio is very high. The
interpretation of these measurements is similar to that of FEV1 using
the appropriate predicted values. FEV6 (the volume exhaled in the first
6 seconds) is sometimes used as an alternative measurement to the
FVC if the spirometer is unable to record beyond 6 seconds, or if the

patient finds prolonged expiratory manoeuvres exhausting. The FEV6
may underestimate the FVC in obstructive disorders, but this is unlike-
ly to significantly alter the interpretation of the results.
Vital capacity: slow vital capacity or forced vital
capacity?
In some patients with obstructive airways disease, the forced vital
capacity (FVC) will underestimate the true vital capacity (VC). This is
because the increase in intrathoracic pressure during the forced
manoeuvre compresses airways, causing early airway closure and gas
trapping. This does not happen in normal lungs. If suspected, it can
be detected by measuring the vital capacity (from full inspiration to
full expiration) without trying to force the air out (sometimes called a
slow or relaxed vital capacity, SVC). Some pulmonary function equip-
ment also allows the vital capacity to be measured as an inspiratory
manoeuvre (inspiratory vital capacity, IVC). Slow vital capacity meas-
urement is sometimes useful for avoiding the dizziness and syncope
occasionally associated with prolonged FVC manoeuvres.
Reversibility
The reversibility of airflow obstruction is often demonstrated by
repeating spirometry after treatment. Most often, a dose of inhaled
beta-agonist (such as salbutamol 2.5 mg by nebuliser) is administered
after the initial test and spirometry is repeated 15–30 minutes later.
Other bronchodilators, such as ipratropium bromide, may also be
used. Alternatively, spirometry can be repeated after a few weeks of
inhaled or oral corticosteroid treatment. It is important to ensure that
bronchodilators have not been taken before the initial test.
Various criteria exist for defining ‘significant’ reversibility. Usually
an improvement of 15% or more and 200 mL or more in FEV1 or FVC
are required, since smaller changes may occur due to the variability of
testing procedure and may occur by chance. In patients who are unable
to perform reproducible tests, even large changes may be due to errors
of measurement. Often both FEV1 and FVC improve and the
FEV1/FVC ratio does not change. Occasionally there is a significant
improvement in FVC with no change in FEV1 and the FEV1/FVC ratio
appears to get smaller. Therefore the FEV1/FVC ratio should not be
used to assess the response to bronchodilators.
Spirometry 9

Reversibility is a characteristic feature of asthma. A significant
improvement in spirometry may suggest the diagnosis of asthma even
if the original measurements were within the ‘normal’ range.
However, in chronic asthma there may be only partial reversibility of
the airflow obstruction.
The airflow obstruction in chronic obstructive pulmonary disease
is largely irreversible. However, a small but significant improvement
in FEV1 can be shown in many chronic obstructive pulmonary disease
patients. Thus it may not be possible to distinguish between chronic
obstructive pulmonary disease and chronic asthma on reversibility
criteria alone. The results should be interpreted in the clinical context.
Reversibility is sometimes used to guide treatment. A large
response to a bronchodilator indicates that there is a potential to
improve airflow obstruction. This may justify a trial of anti-asthma
medication (such as inhaled corticosteroid) in patients otherwise
thought to have chronic obstructive pulmonary disease. However, a
lack of response to a bronchodilator during reversibility testing does
not necessarily mean that the bronchodilator will not provide impor-
tant symptomatic benefits such as an improvement in exercise toler-
ance. The definition of significant reversibility requires that a large
percentage change is needed in patients with severe airways disease.
For example an improvement in FEV1 from 0.6 litres to 0.75 litres
(150 mL) would not be regarded as ‘significant’ because it could be
due to measurement error, even though a real change of this magni-
tude may be a big improvement for the patient.
CHAPTER SUMMARY
➔ Spirometry which is not performed correctly may produce
misleading results.
➔ The FEV1, FVC and FEV1/FVC ratio are all necessary to interpret
spirometry.
➔ An obstructive defect causes a reduction in FEV1 and a reduced
FEV1/FVC ratio.
➔ Restrictive defects cause a reduction in FVC with a normal or
high FEV1/FVC ratio.
➔ 15% or more and 200 mL or more improvement in either FEV1 or
FVC after bronchodilator indicates significant reversibility. The
FEV1/FVC ratio should not be used to assess reversibility.
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Spirometry 11
Clinical examples
Figures in brackets are outside the predicted range.
Patient 1A: age 31, female, European, height 1.68 m, weight
74 kg
History: Intermittent wheeze. Non-smoker.
Technician’s comments: Good patient technique, results were accept-
able and reproducible.
Predicted Measured % predicted
FEV1 litres 3.17 (2.08) (66)
FVC litres 3.99 3.85 96
FEV1/FVC % 79 54
FEF25–75% L/s 3.58 (1.14) (32)
Spirometry was repeated 15 minutes after nebulised broncho-
dilator:
Measured % predicted % change
FEV1 litres 3.40 107 63
FVC litres 4.30 108 12
FEV1/FVC % 79
FEF25–75% L/s 3.14 88
Interpretation: There is mild airflow obstruction on initial spirometry
indicated by the low FEV1 and the low FEV1/FVC ratio. After bron-
chodilator, spirometry is normal with significant improvements in
the FEV1 and a small improvement in FVC, indicating complete
reversibility. In the context of the history, these results suggest
asthma.
Patient 1B: age 50, female, European, height 1.62 m, weight
57 kg
History: Recent onset of wheeze and dyspnoea. Has smoked approx-
imately 20 cigarettes a day for 30 years. ?Late-onset asthma.
Ch 1 Hancox 6/10/05 10:38 AM Page 11

Technician’s comments: Good patient technique, results were accept-
able and reproducible despite frequent cough. Patient had a cigarette
1 hour prior to being tested.
FEV1 litres 2.51 (1.31) (52)
FVC litres 3.31 2.88 87
FEV1/FVC % 75 45
FEF25–75% L/s 2.89 (0.52) (18)
Spirometry was repeated 15 minutes after nebulised broncho-
dilator:
Measured % predicted % change
FEV1 litres (1.60) (64) 22
FVC litres 3.36 102 17
FEV1/FVC % 48
FEF25–75% L/s (0.78) (27) 49
Interpretation: There is moderately severe airflow obstruction on
initial spirometry indicated by the low FEV1 and low FEV1/FVC ratio.
After bronchodilator, there is partial reversibility with significant
improvements in both FEV1 and FVC. Note that the FEV1/FVC ratio
does not change significantly despite the response to bronchodilator.
In view of the history of smoking and the recent onset of symptoms,
these results suggest chronic obstructive pulmonary disease. However,
there is significant reversibility and a trial of corticosteroids to max-
imise lung function may be justified.
Patient 1C: age 77, male, Asian, height 1.63 m, weight 65 kg
History: Gradual onset of dyspnoea over the past year. Has smoked
approximately 10 cigarettes a day for 50 years.
Technician’s comments: Good patient technique, acceptable and
reproducible results.
Ch 1 Hancox 6/10/05 10:38 AM Page 12

FEV1 litres 2.16 1.59 73
FVC litres 3.31 (1.91) (58)
FEV1/FVC % 69 83
FEF25–75% L/s 2.06 2.36 115
Interpretation: There is a restrictive pattern with a moderately reduced
FVC. The FEV1 is at the lower end of the normal range and the
FEV1/FVC ratio is high. The FEF25–75% is at the upper end of the nor-
mal range, suggesting increased mid-expiratory flows despite the
reduced vital capacity. Further pulmonary function tests, including lung
volumes and gas transfer, would be useful in this patient—see Chapters
4 and 5. (A high-resolution CT scan later suggested pulmonary fibro-
sis.) Note that this patient is Asian; the predicted values given are based
on Europeans, and may overestimate the ‘normal’ values.
Patient 1D: age 77, male, European, height 1.64 m, weight
73 kg
History: Gradual onset of dyspnoea and cough over the past few
months. Has smoked approximately 20 cigarettes a day for 30 years,
but gave up smoking 15 years ago. Has been treated with amiodarone
for atrial fibrillation. Has a pet parrot.
Technician’s comments: Good patient technique, but coughed when
trying to expire fully. FVC may be underestimated.
FEV1 litres 2.26 2.08 92
FVC litres 3.45 2.55 74
FEV1/FVC % 68 81
FEF25–5% L/s 2.10 2.09 99
Interpretation: All the measured results are within the predicted
range. However, a restrictive pattern is suggested by the low/normal
FVC and a high FEV1/FVC ratio. The FVC may be underestimated by
the patient’s technique (see technician’s comments). The FEV1 and
FEF25–75% are normal and there is no evidence of airflow obstruction.
Spirometry 13
Ch 1 Hancox 6/10/05 10:38 AM Page 13

In view of the history of exposure to amiodarone and a pet bird (both
of which can cause restrictive lung diseases), further pulmonary func-
tion tests, including lung volumes and gas transfer, are indicated—see
Chapters 4 and 5.
Ch 1 Hancox 6/10/05 10:38 AM Page 14

Pocket Guide to Lung Function Tests - sample chapter

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