Chapter 1 Lung Mechanics

PULMONARY FUNCTION TESTING

Vital Capacity (VC)

The VC is the maximum volume of air that an individual can move in a single
breath. The most useful assessment of the VC is to expire as quickly and forcefully
as possible, i.e., a "timed" or forced vital capacity (FVC). During the FVC maneu
ver, the volume of air exhaled in the first second is called the forced expiratory
volume in 1 sec (FEV1 ). This is illustrated in Figure VIl- 1 - 15.

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FVC
en Figure Vll-1-15 and the following figures
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(in cluding residual volume) instead of
showing only changes in volume.

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t t FEV1 80% (or 0.80)
1 second FVC =

Figure Vll-1 -1 5. Pulmonary Function Test of Forced Vital Capacity (FVC)

There are 2 key pieces of data from a pulmonary function test (PFT) involving
the measurement of FVC:
FVC: This is total volume exhaled.
- Because age, gender, body size, etc., can influence the absolute
amount of FVC, it is expressed as a percent of predicted ( 100% of
predicted being the "ideal") .
FEVl (forced expiratory volume in 1 second): Although this volume
can provide information on its own, it is commonly compared to the
FVC such that one determines the FEVl/FVC ratio.
- This ratio creates a flow parameter; 0.8 (80%) or greater is considered
normal.
Thus, this PFT provides a volume and a flow.
Restrictive pulmonary disease is characterized by reduced volume (low
FVC, but normal flow) .
Obstructive disease is characterized by reduced flow (low FEVl/FVC)

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Section VII Respiration

Physiology of a PFT
The picture on the left of Figure VII- 1 - 16 shows that at the end of an inspiratory
effort to TLC, IPP is very negative. This negative IPP exists throughout the lungs
during a passive expiration and thus the PTM is positive for both alveoli and air
ways.

The picture on the right of Figure VII- 1 - 1 6 shows the situation during a maximal
forced expiration.
A forced expiration compresses the chest wall down and in, creating
a positive IPP. The level of positive IPP generated is dependent upon
effort.
This forced expiration creates a very positive alveolar pressure, in turn
creating a large pressure gradient to force air out of the lungs.
However, this positive IPP creates a negative PTM in the airways. It is
more negative in the large airways, e.g., trachea and main-stem bronchi.
These regions have structural support and thus do not collapse even
though PTM is very negative.
Moving down the airways toward alveoli, the negative PTM ultimately
compresses airways that lack sufficient structural support. This is
dynamic compression of airways.
This compression of airways creates a tremendous resistance to air-
flow. In fact, the airway may collapse, producing infinite resistance.
Regardless, this compression creates a level of resistance that over
whelms any and all other resistors that exist in the circuit and is thus the
dominant resistor for airflow.
Once this occurs, elastic recoil of the lung becomes the effective driving
force for airflow and airflow becomes independent of the effort. This
means airflow is a property of the patient's respiratory system, hence the
reason this test is very diagnostic.
Because this resistance is created in small airways, the entire volume of
the lungs cannot be expired, creating residual volume (RV).

Because PFTs measure flow (FEVl/FVC) and volume, they accurately diagnose
obstructive (low flow) and restrictive disease (low volume, normal flow).

1 52 M E D ICAL
 Chapter 1 Lung Mechanics

O cm Hp O cm Hp

End of Inspiration During a Forced Expiration

Figure Vll-1 -1 6. Dynamic Airway Compression

Obstructive versus Restrictive Patterns

The following figures (Figures VIl- 1 - 17 and VIl- 1 - 18) demonstrate a standard
pulmonary function test, the measurement of FVC, FEV 1, and FEV 1 /FVC.

Obstructive pulmonary disease Bridge to Pathology

Obstructive disease is characterized by an increase in airway resistance that is There are 4 basic pathologic alterations
measured as a decrease in expiratory flow. Examples are chronic bronchitis, asth that can occur in obstructive disease:
ma, and emphysema. Bronchoconstriction

Obstructive pattern Hypersecretion

Total lung capacity (TLC) is normal or larger than normal, but during a I nflammation
maximal forced expiration from TLC, a smaller than normal volume is Destruction of lung parenchyma
slowly expired. (em physema)
Depending upon the severity of the disease, FVC may or may not be
reduced. If severe enough, then FVC is diminished.
Bridge to Pharmacology
Obstructive Normal Treatment of obstructive disease

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includes 132-agonists (short- and
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long-acti ng), M3 blockers such as

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cell stabilizers, leukotriene-receptor

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1 second lFvc tFRCtTLCtRV#FEV,I 1 second

FEV1 = 50% FEV1 80% (or 0.80)
FVC FVC =

Figure Vll-1 -1 7. Obstructive Pattern

M E D I CAL 1 53
Section VII Respiration

Restrictive pulmonary disease

Restrictive pulmonary disease is characterized by an increase in elastic recoil-a
decrease in lung compliance-which is measured as a decrease in all lung volumes.
Reduced vital capacity with low lung volumes are the indicators of restrictive pul
monary diseases. Examples are acute respiratory distress syndrome (ARDS) and in
terstitial lung diseases such as sarcoidosis and idiopathic pulmonary fibrosis (IPF).

Restrictive pattern
TLC is smaller than normal, but during a maximal forced expiration
from TLC, the smaller volume is expired quickly and more completely
than in a norm?I pattern.
Therefore, even though FEV1 is also reduced, the FEV/FVC is often
increased.
However, the critical distinction is low FVC with low FRC and RV.

Restrictive Normal

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1 second I HFVC t FRC .J.TLC t RV t FEV1 I 1 second

FEV1 = 88% FEV1
= 80% (or 0.80)
FVC FVC

Figu re Vll-1-18. Restrictive Pattern

1 54 M E D I CA L
 Chapter 1 Lung Mechanics

Table Vll-1-1. Summary of Obstructive Versus Restrictive Pattern

Variable Obstructive Pattern Restrictive Pattern
e.g., Emphysema e.g., Fibrosis

TLC i J, J,

FEV1 J, J, J,

FVC J, J, J,

FEV1 /FVC J, i or n orma l

Peak flow J, J,

FRC i J,

RV i J,

FVC is always decreased when pulmonary function is significantly compromised.

A decrease in FEV/FVC ratio is evidence of an obstructive pattern. A normal or

increased FEV /FVC ratio is evidence of a restrictive pattern, but a low TLC is
diagnostic of restrictive lung disease.

Flow-Volume Loops
The instantaneous relationship between flow (liters/sec) and lung volume is
useful in determining whether obstructive or restrictive lung disease is present.
In the loop shown in Figure VII- 1 - 1 9, expiration starts at total lung capacity
and continues to residual volume. The width of the loop is the FVC.

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(liters)
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Figure Vll-1 -1 9. Flow-Volume Loop

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Section VII Respiration

Loops found in obstructive and restrictive disease are shown in Figure VII- 1 -20.

Obstructive disease
In obstructive disease, the flow-volume loop begins and ends at abnormally high
lung volumes, and the expiratory flow is lower than normal. In addition, the
downslope of expiration "scallops" or "bows" inward. This scalloping indicates
that at any given lung volume, flow is less. Thus, airway resistance is elevated
(obstructive).

Restrictive disease
In restrictive disease, the flow-volume loop begins and ends at unusually low
lung volumes. Peak flow is less, because overall volume is less. However, when
expiratory flow is compared at specific lung volumes, the flow in restrictive .dis
ease is somewhat greater than normal.

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Lung Volume (liters)
Figure Vll-1 -20. Forced Expiratory Flow-Volume Loop

1 56 M E D I CA L