Pulmonary Function Testing for the

Primary Care Provider

Robert L. Keith MD FCCP

Associate Professor of Medicine
Division of Pulmonary Sciences & Critical Care Medicine
Denver VA Medical Center
University of Colorado Denver School of Medicine

Learning Objectives

Discuss the indications for spirometry and more advanced

pulmonary function testing
Recognize the most common diseases (COPD, asthma, ILD)
associated with specific abnormalities on pulmonary function
testing
Understand the use of pulmonary function testing in preoperative assessment

Mortality Associated With COPD

third

Approximately Half of All Patients With COPD

Are Undiagnosed

COPD Is as Common as Asthma and Diabetes

Outline

Spirometry (airflow)

Full Pulmonary Function Testing

Airflow
Lung Volumes
Diffusion Capacity (DLCO)

Other tests: muscle strength, 6 minute walk, oxygen titration

Arterial Blood Gases

Disease States: COPD, Asthma, ILD, Pulmonary

Hypertension

Spirometry: A Key to Early Detection of

COPD and other Lung Disease

Spirometry in primary care setting is crucial1,2

Simple, inexpensive, office-based
Consider every smoker and recent quitter (esp. > 45 years old)

Decline in lung function is often undetected3

Patients may be asymptomatic or may unconsciously modify
activity to compensate

Identification and aggressive intervention can improve

prognosis4-6
Abnormal spirometry may also improve smoking cessation
rates

1. Ferguson GT et al. Chest. 2000;117:1146-1161. 2. NLHEP. Chest. 1998;113(suppl):123S-163S. 3. NCAP. J Respir Dis.
2000;21(suppl):S5-S21. 4. CDC. MMWR. 1990;39(RR-12):2-10. 5. Anthonisen NR et al. JAMA. 1994;272:1497-1505.
6. Kanner RE. Med Clin North Am. 1996;80:523-547.

Spirometry

Measures volume of air forcibly exhaled from fully

inflated lungs over time1
Simple and inexpensive office-based method of
evaluating lung function1,2. It takes 10-15 minutes and
carries no risk. EFFORT DEPENDENT
Lung function should be followed over time and used to
assess effectiveness of therapy1
Spirometry should be performed in all smokers over the
age of 45 to screen for COPD
over 25% will have abnormal results.

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Ferguson GT et al. Chest. 2000;117:1146-1161.

Handheld Devices for Screening and Early Detection of COPD

Spirometry

Measures volume of air (liters)

exhaled or inhaled as a function of
time.
The amount of air displaced by a
maximal exhalation or inhalation
maneuver is called the vital
capacity (VC)
FVC maneuver :patient inhales
maximally then exhales as rapidly
and completely as possible (must
exhale for at least 6 seconds).
FEV1:forced expiratory volume in
first second
Flows are measured or calculated
as the rate of volume change as a
function of time (liters/second)
FEV1/FVC is expressed as a
percentage

8
7
6
5
4
3
2
1
0
-2
-3
-4
-5

Normal

Predicted
Actual

COPD
8
6

1 sec

TLC

RV

Flow (L/s)

Flow (L/s)

Flow Volume Loops

2
0
-2
-4

IC
6

1 sec

IC

-6

Volume (L)

Volume (L)

Normal Values
(based on age, sex, height, weight, ethnicity)
Pulmonary function
test
Normal value (95% confidence interval)
FEV1

80% to 120%

FVC

80% to 120%

FEV1/FVC ratio

Within 5% of predicted ratio

TLC

80% to 120%

FRC

75% to 120%

RV

75% to 120%

DLCO

>60% to <120%

Salzman SH. J Resp Dis 1999;20:812.

Spirometry Interpretation
Step 1: Acceptability and Reproducibility
Step 2: Differentiation between obstructive disorders and
restrictive disease
Step 3: Bronchodilator challenge (albuterol) for reversible
airway obstruction
Step 4: Lung volumes and diffusion may aid to distinguish
asthma from COPD and may provide clues regarding
restrictive lung disease
Multiple measurements (usually at least 3) should be
done on each subject

Spirometry Interpretation

Diagnosis of COPD1
FEV1 <80% predicted
FEV1/FVC <70% predicted

Normal FEV1 and FEV1/FVC usually exclude COPD

Peak Expiratory Flow underestimates severity of COPD and
cannot be used for diagnosis
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
FEV1/FVC = % sec ratio.

1. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121.

Acceptability

Normal

Cough

Variable effort

Common Flow Volume Loops

Normal

Obstruction

Restriction

Severe obstruction

Obstructive Lung Disease

FEV1> 80%;Normal
Mild disease: FEV1 = 60-80%
predicted
Moderate disease: FEV1 =
40-60% predicted

Moderate

Severe disease: FEV1<40%

examples: (asthma, COPD,
chronic bronchitis)
Severe

Bronchodilator Challenge

Post-bronchodilator spirometry Administration of

albuterol by metered-dose inhaler (MDI) is indicated
during an initial workup if baseline spirometry
demonstrates airway obstruction or if asthma is
suspected. Spirometry is repeated ten minutes after
administration of a bronchodilator (proper MDI technique
is important).
In a patient with airway obstruction, an increase in the
FEV1 or FVC of more than 12% and > 0.2 L (200 ml) is a
positive bronchodilator response.
Lack of an acute bronchodilator response should not
preclude a 6-8 week trial of bronchodilators and/or
inhaled corticosteroids, with reassessment of clinical
status and change in FEV1 at the end of that time.

10

Restrictive Lung Disease

Both FEV 1 and FVC are reduced

proportionately
FEV1/FVC is normal or elevated
Restriction cannot be diagnosed
by spirometry alone
Lung volumes are necessary to
make the diagosis
3 groups of disorders cause
restrictive lung disease
Intrinsic Lung Disease:
inflammation or scarring of lung
tissue (ILD, acute pneumonitis)
Extrinsic Disorders: chest wall or
pleural disease that limit lung
expansion
Neuromuscular Disorders:
decreased ability of respiratory
muscles to inflate/deflate the lungs

Contraindications to Spirometry
1. Acute disorders affecting test performance (e.g.,
vomiting, nausea, vertigo)
2. Hemoptysis of unknown origin (FVC maneuver may
aggravate underlying condition.)
3. Pneumothorax
4. Recent abdominal or thoracic surgery
5. Recent eye surgery (increases in intraocular
pressure during spirometry)
6. Recent myocardial infarction or unstable angina
7. Thoracic aneurysms (risk of rupture because of
increased thoracic pressure)
TJ. BARREIRO and I PERILLO, AFP, 2004

11

Spirometry vs.
Full Pulmonary Function tests

Spirometry: Detect obstructive lung disease, suggestion of

restrictive lung disease, degree of bronchodilator response,
flow volume loop may indicate intra- and extrathoracic
obstruction
National Lung Health Education Project advocates all current
and former smokers > 45 years of age should have spirometry
done to detect COPD
PFTs: Include Lung volumes, diffusion capacity (DLCO)
Full PFTs typically done in a pulmonary laboratory and require
a body plethysmograph (aka a body box)

PFTS:
Pulmonary Preoperative Assessment
1. Prior to lung resection/pneumonectomy
2. Chronic lung disease: screening for disease using PFTs is not
warranted without suggestive history and physical. However, in
those with known lung disease (COPD, asthma) can estimate
disease severity and prompt intervention1
3. The degree of airways obstruction (or an elevated pCO2 for
patients with COPD) predicts the risk of postoperative
pulmonary complications, such as atelectasis, pneumonia, and
the need for prolonged mechanical ventilation. DLCO < 40%
predicts post-operative pulmonary complications.
4. If spirometry demonstrates moderate to severe obstruction and
the surgery can be delayed, a prophylactic program of
pulmonary hygiene, including smoking cessation, inhaled
bronchodilators or steroids, and antibiotics for bronchitis, can
reduce risk

Doyle, R., Chest, 1999

12

Risk Reduction Strategies

Outline

Spirometry (airflow)

Full Pulmonary Function Testing

Lung Volumes
Diffusion Capacity (DLCO)

Other tests: muscle strength, 6 minute walk, oxygen titration

Arterial Blood Gases

Disease States: COPD, Asthma, ILD, Pulmonary

Hypertension

13

Respiratory Muscle Strength Testing

Consider testing in patients with dyspnea, hypercarbia, &

hypoxemia
MIP (maximal inspiratory pressure): direct test of inspiratory
muscle strength by inhaling against a close valve
Useful in all patients with suspected neuromuscular disease

MEP (maximal expiratory pressure): test of expiratory muscle

strength
Diseases associated with muscle weakness: ALS, myasthenia
gravis, polymyositis, hypothyroidism, SLE,
hypophosphatemia, critical illness polyneuropathy (seen after
steroid use)

Six-Minute Walk1

Measures distance walked in 6 minutes on level ground

while being actively coached and encouraged
Reproducible practical measure of impairment and
exercise tolerance (the treadmill test for the lung)
May correlate with functional capacity and dyspnea better
than FEV1
The major endpoint in most studies involving treatment of lung
diseases (COPD, PH, ILD)
Can be used to follow effect of therapy and encourage chronic
inhaled medication use
Improvements of 40m are clinically relevant

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21.

14

Supplemental Oxygen

Indicated for PaO2 <55 mm Hg or SaO2 <88%1

Improves1-4:

Survival in hypoxemic patients

Cognitive function, affect
Exercise performance
Sleep quality
Activities of daily living

Supervised walk (can do a 6 minute walk at the same time)

with respiratory therapist to determine oxygen needs.
Used to evaluate oxygen conserving devices: demand/
pulsatile systems, Helios

Outline

Spirometry (airflow)

Full Pulmonary Function Testing

Lung Volumes
Diffusion Capacity (DLCO)

Other tests: muscle strength, 6 minute walk, oxygen titration

Arterial Blood Gases

Disease States: COPD, Asthma, ILD, Pulmonary

Hypertension

15

Arterial Blood Gases

Direct measurement of pH, paO2 and pCO2 from a radial

artery specimen
Test must be run immediately on the sample after it is stored
on ice
Provide important clues to underlying pulmonary status
Oxygenation
Ventilation (i.e. elevated pCO2 indicates hypoventilation)
Suggests chronicity of disease (i.e. a normal pH with an
elevated pCO2 suggests a chronic condition)
Carbon monoxide measurements

Outline

Spirometry (airflow)

Full Pulmonary Function Testing

Lung Volumes
Diffusion Capacity (DLCO)

Other tests: muscle strength, 6 minute walk, oxygen titration

Arterial Blood Gases

Disease States: COPD, Asthma, ILD, Pulmonary

Hypertension

16

COPD

Leading cause: smoking1

3rd leading cause of death in US as of early 2011

Only major chronic disease with mortality still rising 2,3

Approximately 30 million have COPD, only 16 million are

diagnosed2

More prevalent than asthma4

Preventable and treatable1

The primary care clinician (PCC) plays a critical role in early

diagnosis and treatment1,5

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. CDC. MMWR. 1999;48:664-678. 3. Higgins MW et al. In: Clinical
Epidemiology of COPD. 1990:23-43. 4. Mannino et al. http://www.cdc.gov/mmwr/preview/mmwrhtml/00052262.htm.
5. NLHEP. Chest. 1998;113(suppl):123S-163S.

COPD: Key Definitions1,2

Simple chronic bronchitis

Chronic cough and sputum production

Chronic obstructive bronchitis

Airflow obstruction: reduced forced expiratory volume in
1 second (FEV1) and ratio of FEV1 to forced vital capacity (FVC)
(FEV1/FVC)
Chronic cough and sputum production

Emphysema

Irreversible enlargement of air spaces distal to terminal

bronchioles
Alveolar wall destruction
Airflow obstruction
1. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77S121. 2. NCAP. J Respir Dis. 2000;21(suppl):S5-S21.

17

Risk Factors for COPD

Smoking is the predominant risk factor1,2

Implicated in >90% of US patients with COPD

Others include1:

Air pollution
Poor nutrition
Childhood respiratory infections
Preexisting bronchial hyperreactivity
a1-Antitrypsin deficiency (genetic, rare)
Occupational and environmental exposure (eg, coal dust, silica)

1. NCAP. J Respir Dis. 2000;21(Suppl):S5-S21. 2. Buist AS, Vollmer WM. In: Textbook of Respiratory Medicine. 1994:1259-1287.

Natural History of COPD

Normal decline in FEV1: 25 to 30 mL per year from peak

at age 251
FEV1 decline in smokers: 45 to 60 mL/y1
Approximately 20% of smokers have accelerated decline:
up to 150 to 200 mL/y

More cigarettes smoked = steeper rate of decline2

Quitting at any age: better pulmonary function,
slower rate of decline than those who continue to smoke2,3
Return to normal rate of decline

FEV1, forced expiratory volume in 1 second.

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121.
3. Higgins MW, et al. JAMA. 1993;269:2741-2748.

18

FEV1 (% of value at age 25 y)

Age-Related Decline in FEV1 Is

Accelerated in Smokers
Never smoked or not susceptible to smoke
Stopped at 45 y
Stopped at 65 y
Smoked regularly and susceptible to its effects

100
75
50
Disability
25
Death
0
25

50

Age (y)

75

FEV1, forced expiratory volume in 1 second.

Adapted with permission from Fletcher C, Peto R. BMJ. 1977;1:1645-1648.

Spirometry: A Key to Early

Detection of COPD

Spirometry in primary care setting is crucial1,2

Simple, inexpensive, office-based
Consider every smoker and recent quitter (esp. > 45
years old)

Decline in lung function is often undetected3

Patients may be asymptomatic or may unconsciously
modify activity to compensate

Identification and aggressive intervention can improve

prognosis4-6

1. Ferguson GT et al. Chest. 2000;117:1146-1161. 2. NLHEP. Chest. 1998;113(suppl):123S-163S. 3. NCAP. J Respir

Dis. 2000;21(suppl):S5-S21. 4. CDC. MMWR. 1990;39(RR-12):2-10. 5. Anthonisen NR et al. JAMA.
1994;272:1497-1505. 6. Kanner RE. Med Clin North Am. 1996;80:523-547.

19

COPD Stages of Severity

Category

FEV1

Socioeconoic
Ipact

1 (mild)

50% to 79%
of predicted

O Majority of patients
O Minimal impact on HRQOL
O Modest cost

2 (moderate)

35% to 49%
of predicted

O Minority of patients
O Significant impact on HRQOL
O High cost

3 (severe)

<35% of
predicted

O Minority of patients
O Profound impact on HRQOL
O Very high cost

HRQOL, health-related quality of life; cost, per capita health care expenditure
Spirometric severity criteria adapted from American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121.

20

The Socioeconomics of Tobacco Abuse

90% of surveyed Americans know smoking is bad for you

Nearly all of the increases in life expectancy in the last few
decades have been in better-educated Americans
Having gone to college at all (no degree needed) translates
into 5 additional years of life expectancy
"the gap in cancer death rates between college graduates and
those who only went to high school is widening," as "the least
educated" men "died of cancer at rates more than 2 1/2 times
that of men with college degrees. Meanwhile, "for women, the
numbers aren't as complete but suggest a widening gap also."

Smoking rates associated with education level

9-11th grade completed: 35%
Graduate degree: 7%
Seatbelt and Helmet use also associated with education level

41

Smoking Cessation Strategies

Smoking cessation is the only disease modifying treatment for

COPD

Advice from physician is the most important motivator1

Pharmacologic interventions1-3
Antidepressants (bupropion/Zyban)
Nicotine replacement therapy
Combination pharmacotherapy

Combination of behavior modification and pharmacologic

intervention is better than either alone1

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Jorenby DE et al. N Engl J Med. 1999;340:685-691. 3. Appel D. Am Rev Respir
Dis. 1987;135:354.

21

Case 1
HPI: 70 yo male referred for SOB. Lifelong smoker (2ppd for at least 50
yrs, quit about 2 years ago). + DOE, can not work on his ranch much
anymore. Admits to cough and clear sputum in the morning. Has
lost about 20# in the last year.
EXAM: T 37.6, 85, 143/75, RA O2 sat 90%, drops to 85% with walking
Pul: barrel chested, decreased BS throughout, soft exp
wheeze B.
Cor: RRR with loud P2
Ext: no edema
LAB: WBC 6.8, Na 134, BUN 11, glucose 86. RA ABG: 7.43/37/56
Spirometry:
CXR:
Management:

22

23

Case 1
Spirometry: Severe Airflow Limitation
Assessment: Severe COPD, hypoxemia with exertion
Management: Oxygen, Inhaled Bronchodilators (Tiotropium,
Albuterol, Salmeterol), education regarding COPD
Follow-up clinic visit: Improved DOE (alb use about 1-2x per
week), repeat spirometry showed FEV1 = 1.1 and FEV1/FVC
ratio of 43% (moderate COPD by ATS criteria)

Asthma

Chronic inflammatory lung condition resulting in airway

narrowing, airflow limitation, altered lung mechanics
Affects 7% of US population (18 million people)
Classic symptoms: wheezing, cough, dyspnea, chest
discomfort
Methacholine challenge: hyper-responsiveness to inhaled
irritants
PFTs: reduced FEV1, reduced FEV1/FVC ratio
Not all asthmatics have abnormal spirometry
Hyperinflated lung volumes
Normal DLCO (unlike COPD)

24

Differentiating COPD From Asthma

Diagnosis

Asthma

COPD

Onset

Anytime
(often childhood/early
adulthood)1

Later in life (midlife)1

Usual etiology

Immunologic stimuli, family

history of asthma1

Cigarette smoking,
exposure
to other risk factors1

Course

Usually intermittent1

Chronic, progressive1

Airflow limitation

Largely reversible1

Partially reversible1

Clinical features

Wheeze, chest tightness,

cough, episodic dyspnea2

Persistent or worsening
dyspnea, chronic cough/
sputum1

Inflammatory cell

Eosinophils, macrophages3

Neutrophils,
macrophages3,4

Response to
steroids

Inhibits inflammation5

Little or no effect on
inflammation4

1. Pauwels RA, et al. Am J Respir Crit Care Med. 2001; 163:1256-1276.

2. NLHEP Executive Committee. Chest.1998;113(suppl 2):123S-163S.
3. Global Initiative for Chronic Obstructive Lung Disease teaching slide kit. Available at: http://www.goldcopd.com/slides/download.ppt.
4. Barnes PJ. N Engl J Med. 2000;343:269-280.
5. Wenzel S. Inflammation in asthma. National Jewish Medical and Research Web site. Available at: http://asthma.nationaljewish. org/
about/what/inflammation.php. Accessed March 29, 2004.

Flow-Volume Loops in Asthma

25

Methacholine Challenge Testing

Irvin CG, Bronchoprovocation Testing,

UpToDate, 2005

Pulmonary Arterial Hypertension (PAH)

Pulmonary Circulation is a low pressure, low resistance, high

capacitance system

PAH + resting pulmonary artery pressure > 25 mm Hg

Idiopathic PAH (formerly Primary Pulmonary Hypertension)

Secondary PAH occurs in:

Connective tissue disease (esp. scleroderma)

Advanced lung disease with hypoxemia (ILD, COPD)
Sleep apnea
Congenital heart disease
Advanced liver disease
Chronic thromboembolic disease
HIV

26

PAH: Clinical Findings

Symptoms/Signs: DOE, Chest pain, syncope, R heart failure

(LE edema, JVD, hepatic congestion)
Lab findings: polycythemia (suggesting chronic hypoxia),
Hypoxemia on ABG, hypercoagulability
CXR: cardiomegaly with enlarged pulmonary arteries,
parenchymal lung disease may be present (esp in secondary)
PFTs: Isolated decrease in diffusion capacity.
If associated with other lung diseases (COPD, ILD) PFTs will
reflect underlying pathology

Pre-operative Assessment

Spirometry can help determine risk of post-op complications

for thoracic and upper abdominal surgery
Degree of airflow obstruction, or elevated pCO2 in COPD,
predicts risk of atelectasis, pneumonia and prolonged
mechanical ventilation
If FEV1<50%, and surgery can be delayed, smoking
cessation, inhaled medications, and antibiotics for bronchitis
will reduce risk

27

Pre-operative Assessment - Lung Surgery

pCO2 > 45 mmHg is a risk factor

For lung resection surgery (lobectomy, wedge resection)
spirometry and quant V/Q can be used to predict remaining
lung function
Lower limit of remaining FEV1 is approx 1 liter

ACCP considers increased risk for patients with post-op FEV1

or DLCO of < 40% predicted
Cardiopulmonary exercise test to determine VO2max (if < 10
ml/kg/min or 35% predicted would consider non-surgical
interventions)

Summary and Conclusions

Spirometry is critical to diagnosing lung disease and

differentiating COPD from asthma
Full pulmonary function testing (lung volumes, diffusion
capacity, muscle strength testing) can further aid in diagnosis
and management of lung disease
National Lung Health Education Project advocates all current
or former smokers > 45 years of age should have spirometry
6 minute walk - the treadmill test for the lung
Supplemental Oxygen: improves survival, exercise
performance, and ADLs

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. NLHEP. Chest. 1998;113(suppl):123S-163S. 3. Ferguson GT et al. Chest
2000;117:1146-1161. 4. Higgins MW et al. JAMA. 1993;269:2741-2748.

28

Summary and Conclusions

COPD is the 4th leading cause of death in US2, 12th largest

disease burden in the world (projected to become the 5th)
Primary care team has major role in detection and treatment
of lung disease
Office-based spirometryan essential tool for diagnosis and
monitoring1-3
Distinguishing COPD from asthma: first step in diagnosis1

Smoking cessation can reduce rate of FEV1 decline4

Patient education: key to successful management and
treatment of lung disease

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77S121.

29