Overview of pulmonary function testing in adults
- Meredith C McCormack, MD, MHS
Meredith C McCormack, MD, MHS
- Assistant Professor of Medicine
- Medical Director, Pulmonary Function Laboratory Pulmonary and Critical Care Medicine Johns Hopkins University
Evaluation of pulmonary function is important in many clinical situations, both when the patient has a history or symptoms suggestive of lung disease and when risk factors for lung disease are present, such as occupational exposure to agents with known lung toxicity .
The European Respiratory Society and the American Thoracic Society have published guidelines for the measurement and interpretation of pulmonary function tests (PFTs) [2-5].
An overview of pulmonary function testing will be presented here, summarizing the types of PFTs and their indications. Specific aspects of pulmonary function testing are discussed elsewhere. (See "Office spirometry" and "Reference values for pulmonary function testing" and "Diffusing capacity for carbon monoxide" and "Use of pulmonary function testing in the diagnosis of asthma" and "Bronchoprovocation testing" and "Overview of pulmonary function testing in children".)
PULMONARY FUNCTION TESTS
The major types of pulmonary function tests (PFTs) are spirometry, spirometry before and after a bronchodilator, lung volumes, and quantitation of diffusing capacity for carbon monoxide. Additional PFTs, such as measurement of maximal respiratory pressures, flow-volume loops, submaximal exercise testing, and bronchoprovocation challenge, are useful in specific clinical circumstances (table 1).
Spirometry — Spirometry, the most readily available and useful pulmonary function test, measures the volume of air exhaled at specific time points during a forceful and complete exhalation after a maximal inhalation. The total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled in the first second, known as the forced expiratory volume in one second (FEV1), and their ratio (FEV1/FVC) are the most important variables reported. The test takes 10 to 15 minutes and carries minimal risk (eg, rarely syncope). The technique for performing spirometry and interpretation of results are described separately. (See "Office spirometry" and "Flow-volume loops".)
- Crapo RO. Pulmonary-function testing. N Engl J Med 1994; 331:25.
- Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948.
- 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; 44:1428.
- Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung volumes. Eur Respir J 2005; 26:511.
- Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26:319.
- Aaron SD, Dales RE, Cardinal P. How accurate is spirometry at predicting restrictive pulmonary impairment? Chest 1999; 115:869.
- Tashkin DP, Celli B, Decramer M, et al. Bronchodilator responsiveness in patients with COPD. Eur Respir J 2008; 31:742.
- Modrykamien AM, Gudavalli R, McCarthy K, et al. Detection of upper airway obstruction with spirometry results and the flow-volume loop: a comparison of quantitative and visual inspection criteria. Respir Care 2009; 54:474.
- Washko GR, Hunninghake GM, Fernandez IE, et al. Lung volumes and emphysema in smokers with interstitial lung abnormalities. N Engl J Med 2011; 364:897.
- Bruschi C, Cerveri I, Zoia MC, et al. Reference values of maximal respiratory mouth pressures: a population-based study. Am Rev Respir Dis 1992; 146:790.
- Enright PL, Kronmal RA, Manolio TA, et al. Respiratory muscle strength in the elderly. Correlates and reference values. Cardiovascular Health Study Research Group. Am J Respir Crit Care Med 1994; 149:430.
- 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.
- Enright PL. The six-minute walk test. Respir Care 2003; 48:783.
- Swigris JJ, Wamboldt FS, Behr J, et al. The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference. Thorax 2010; 65:173.
- Swigris JJ, Olson AL, Shlobin OA, et al. Heart rate recovery after six-minute walk test predicts pulmonary hypertension in patients with idiopathic pulmonary fibrosis. Respirology 2011; 16:439.
- 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; 37:150.
- Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155:1278.
- du Bois RM, Weycker D, Albera C, et al. Six-minute-walk test in idiopathic pulmonary fibrosis: test validation and minimal clinically important difference. Am J Respir Crit Care Med 2011; 183:1231.
- Holland AE, Hill CJ, Conron M, et al. Small changes in six-minute walk distance are important in diffuse parenchymal lung disease. Respir Med 2009; 103:1430.
- Mathai SC, Puhan MA, Lam D, Wise RA. The minimal important difference in the 6-minute walk test for patients with pulmonary arterial hypertension. Am J Respir Crit Care Med 2012; 186:428.
- Gilbert C, Brown MC, Cappelleri JC, et al. Estimating a minimally important difference in pulmonary arterial hypertension following treatment with sildenafil. Chest 2009; 135:137.
- Puhan MA, Chandra D, Mosenifar Z, et al. The minimal important difference of exercise tests in severe COPD. Eur Respir J 2011; 37:784.
- Puhan MA, Mador MJ, Held U, et al. Interpretation of treatment changes in 6-minute walk distance in patients with COPD. Eur Respir J 2008; 32:637.
- Wise RA, Brown CD. Minimal clinically important differences in the six-minute walk test and the incremental shuttle walking test. COPD 2005; 2:125.
- Parreira VF, Janaudis-Ferreira T, Evans RA, et al. Measurement properties of the incremental shuttle walk test. a systematic review. Chest 2014; 145:1357.
- Probst VS, Hernandes NA, Teixeira DC, et al. Reference values for the incremental shuttle walking test. Respir Med 2012; 106:243.
- Harrison SL, Greening NJ, Houchen-Wolloff L, et al. Age-specific normal values for the incremental shuttle walk test in a healthy British population. J Cardiopulm Rehabil Prev 2013; 33:309.
- Singh SJ, Morgan MD, Scott S, et al. Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax 1992; 47:1019.
- Singh SJ, Jones PW, Evans R, Morgan MD. Minimum clinically important improvement for the incremental shuttle walking test. Thorax 2008; 63:775.
- Win T, Jackson A, Groves AM, et al. Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer. Thorax 2006; 61:57.
- Revill SM, Morgan MD, Singh SJ, et al. The endurance shuttle walk: a new field test for the assessment of endurance capacity in chronic obstructive pulmonary disease. Thorax 1999; 54:213.
- Singh SJ, Morgan MD, Hardman AE, et al. Comparison of oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. Eur Respir J 1994; 7:2016.
- Feiner JR, Severinghaus JW, Bickler PE. Dark skin decreases the accuracy of pulse oximeters at low oxygen saturation: the effects of oximeter probe type and gender. Anesth Analg 2007; 105:S18.
- van der Molen T, Østrem A, Stallberg B, et al. International Primary Care Respiratory Group (IPCRG) Guidelines: management of asthma. Prim Care Respir J 2006; 15:35.
- Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program. Chest 2000; 117:1146.
- Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011; 155:179.
- Miller MR, Quanjer PH, Swanney MP, et al. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest 2011; 139:52.
- Swanney MP, Ruppel G, Enright PL, et al. Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax 2008; 63:1046.
- Dykstra BJ, Scanlon PD, Kester MM, et al. Lung volumes in 4,774 patients with obstructive lung disease. Chest 1999; 115:68.
- Scanlon PD, Connett JE, Waller LA, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir Crit Care Med 2000; 161:381.
- Kohansal R, Martinez-Camblor P, Agustí A, et al. The natural history of chronic airflow obstruction revisited: an analysis of the Framingham offspring cohort. Am J Respir Crit Care Med 2009; 180:3.
- Vestbo J, Prescott E, Lange P. Association of chronic mucus hypersecretion with FEV1 decline and chronic obstructive pulmonary disease morbidity. Copenhagen City Heart Study Group. Am J Respir Crit Care Med 1996; 153:1530.
- Leach, RM, Davidson, AC, Chinn, S, et al. Portable liquid oxygen and exercise ability in severe respiratory disability. Thorax 1992; 47:781. Erratum in Thorax 1993; 48:192.
- Boros PW, Enright PL, Quanjer PH, et al. Impaired lung compliance and DL,CO but no restrictive ventilatory defect in sarcoidosis. Eur Respir J 2010; 36:1315.
- Hadeli KO, Siegel EM, Sherrill DL, et al. Predictors of oxygen desaturation during submaximal exercise in 8,000 patients. Chest 2001; 120:88.
- Zibrak JD, O'Donnell CR, Marton K. Indications for pulmonary function testing. Ann Intern Med 1990; 112:763.
- Olsen GN. The evolving role of exercise testing prior to lung resection. Chest 1989; 95:218.
- PULMONARY FUNCTION TESTS
- - Post-bronchodilator
- - Flow-volume loop
- Lung volumes
- Maximal respiratory pressures
- Diffusing capacity
- Submaximal exercise testing
- - Six-minute walk test
- - Incremental shuttle walk test
- - Endurance shuttle walk test
- Pulse oxygen saturation
- Arterial blood gases
- CLINICAL USE OF PULMONARY FUNCTION TESTS
- Chronic dyspnea
- Chronic obstructive pulmonary disease
- Restrictive ventilatory defect
- Preoperative testing
- Impairment or disability
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS