Pulmonary Function Tests:
Pulmonary Function Tests:
Indications for PFTs have widened substantially, ranging from screening smokers for early pulmonary disease or screening patients for drug-induced lung toxicity to determining the diagnosis and prognosis of pulmonary conditions (Table 1).
In this article, we will address the use of PFTs in common pulmonary diseases and the indications most relevant to the primary care practitioner.
Screening for obstructive lung disease in smokers.The significance of office spirometric screening for chronic obstructive pulmonary disease (COPD) in high-risk patients (such as persons who have smoked for more than 10 years) is well established. Spirometric signs of airway obstruction have been found in 24.3% of asymptomatic smokers compared with 14.4% of nonsmokers.1 The Lung Health Study showed that early intervention with smoking cessation in those identified to be at risk for COPD could modify disease progression.2
The Third National Health and Nutrition Examination Survey suggested that undiagnosed airflow obstruction was found in 12% of patients surveyed and was more common than physician-diagnosed COPD (3.1%) or asthma (2.7%).3 After adjusting for smoking, obesity, and comorbid conditions, the risk of impaired health and functional status with undiagnosed airflow obstruction was independently associated with the severity of forced expiratory volume in 1 second (FEV1) impairment.3
A consensus statement from the National Lung Health Education Program recommends that all patients aged 45 years and older who are current smokers and all patients with respiratory symptoms undergo office spirometry or diagnostic spirometry.4 There are no recommendations to perform screening PFTs for asymptomatic nonsmokers, because no studies have shown any advantage in doing so.
Preoperative screening for lung disease. PFTs have a clear role in preoperative screening for lung resection surgery, but the role of PFTs in non-lung resection surgery is less clear. This is partly due to the lack of a unified definition of postoperative pulmonary complications in studies examining this role; the complex interaction of respiratory factors (obstructive or restrictive pulmonary disease, respiratory muscle weakness, smoking) and nonrespiratory factors (age, obesity, nutritional status, operative factors, proximity to diaphragm, type of anesthesia) affecting postoperative respiratory status; and the rapid pace of change in surgical techniques.
The 1990 American College of Physicians' guidelines indicated that PFTs should not be done in patients without evidence of lung disease at physical examination who were to undergo nonthoracic surgical procedures.5 However, PFTs were recommended for patients with a history of tobacco use or dyspnea who were to undergo coronary artery bypass grafting or upper abdominal surgery and for all patients who were to undergo lung resection.5 The role of PFTs in these settings is "not to determine candidacy, but to guide postoperative care to reduce pulmonary complications."6 No studies have reported results of routine preanesthesia office spirometry.7
The role of PFTs in evaluating respiratory symptoms such as dyspnea, cough, and wheezing is obvious. PFTs can identify different physiologic patterns of abnormal lung function, including obstructive, restrictive, upper airway, and neuromuscular weakness patterns; however, they cannot pinpoint a specific disease entity (Table 2 and Figure).
Be careful not to interpret PFT results as "normal" or "abnormal" without incorporating them in the clinical context. For example, patients with primary pulmonary hypertension (PH) may have completely normal PFT findings, especially in the early stages of disease,8 whereas an obese patient may have a small-airway obstruction pattern with a decrease in expiratory reserve volume in the absence of significant pathology, an abnormality that usually disappears with weight reduction.9
Obstructive airway diseases. PFTs play an essential role in the diagnosis and grading of severity of obstructive airway diseases. Measures of airflow limitation include the following: peak expiratory flow (PEF), FEV1, forced vital capacity (FVC), FEV1:FVC, and flow-volume loops. Measurements of FEV1, FVC, and FEV1:FVC are very reproducible, with coefficients of variation usually at 5% or less if done in certified laboratories that follow the American Thoracic Society (ATS) standardization guidelines.10
FEV1:FVC has been shown to be very sensitive to the presence of airflow limitation.11 However, normal spirometric measurements may not be sufficient to exclude mild intermittent asthma when patients are asymptomatic.12 In this case, bronchoprovocation testing may be the only way to establish the diagnosis of asthma.13
Other PFTs, such as measurements of lung volumes and D
Interstitial lung disease.PFTs play an essential role in the diagnosis of interstitial lung disease (ILD). In addition to the commonly encountered restrictive pattern (decreased TLC, decreased vital capacity [VC], and increased FEV1:FVC) seen with ILD, other abnormalities on PFTs may suggest an alternative diagnosis. Spirometric evidence of airway obstruction is frequently found in patients with sarcoidosis, rheumatoid arthritis, eosinophilic granuloma, lymphangioleiomyomatosis, and obliterative bronchiolitis. Table 3 categorizes abnormalities seen with some common types of ILD.14
Changes in D
PFTs (including D
Pulmonary hypertension.PFTs are not helpful in diagnosing PH, but they are used in determining the cause of secondary PH, such as airway disease, ILD, and neuromuscular/chest wall diseases. PFTs are also used in patients with PH who are being considered for lung transplantation surgery.
In primary PH, PFT findings may be normal or show a restrictive defect and/or decreased D
PFTs are excellent tools for evaluating respiratory disease severity, hence providing valuable information to assess prognosis and the management plan.
Obstructive lung diseases.Once FEV1:FVC indicates airway obstruction, FEV1 or PEF (besides other clinical parameters) can be used in evaluating the severity of asthma (Table 4).17 PFTs also help determine the prognosis in patients with asthma by identifying the degree of lung function decline. In a 15-year follow-up study, the decline in FEV1 normalized for height was greater among persons with asthma than among those without the disease.18 Other studies have shown that the decline in FEV1 is more pronounced if measured repeatedly early after the diagnosis and in asthmatic patients who smoke.
FEV1 decline in patients with asthma is significantly influenced by baseline FEV1, disease duration, and FEV1 variability. Moreover, the rate of FEV1 decline appears to increase in younger persons who have a poor baseline FEV1 compared with those who have a higher baseline FEV1.19 It is, therefore, surprising that most physicians appear to rely solely on subjective assessments of the patient's asthma and rarely measure FEV1 or FEV1:FVC.
The ability of routine PFTs to identify patients at risk for a fatal or near-fatal asthma attack is somewhat debated. Prospective case-control studies have failed to document that routine PFTs predict near-fatal asthma.20,21 However, in one retrospective review, Lee and colleagues22 were able to distinguish patients who required intubation and mechanical ventilation (as a measure of near-fatal asthma) from those who did not. They used an index that combined the degree of airway narrowing (measured as the provocative dose of inhaled histamine or methacholine required to produce a 20% fall in FEV1 [PD20]) and excessive bronchoconstriction (reflected by the maximal percentage fall in FVC at PD20 [Δ FVC%]) in a bronchoprovocation test: Δ FVC%/log (PD20).22
Despite the controversy surrounding the conclusion by Traver et al23 that FEV1 is the most powerful predictor of mortality in COPD patients (Table 5), PFTs, especially FEV1, continue to be very important tools in determining prognosis in COPD. Hodgkin24 noted that FEV1 of less than 0.75 L is associated with a mortality rate of about 30% at 1 year and 95% at 15 years.
A recent study showed that the categorization of patients with COPD based on the level of dyspnea was more discriminating than staging of disease severity using the ATS guideline (that uses FEV1) with respect to 5-year survival.25 Decreased D
Studies have suggested a good correlation between the degree of D
Other functional tests to predict prognosis in COPD include CPET, the 6MWT, and the shuttle walk test. The 6MWT is a relatively easy test to administer in the PFT laboratory and, if standardized, can be very helpful in grading the functional disability, and therefore prognosis, of COPD patients. Kessler and colleagues30 found that the risk of hospitalization is significantly increased in patients with COPD if their 6MWT distance is 367 m or less. In a recent ATS position statement, the 6MWT is indicated as a predictor of morbidity and mortality in COPD.31
Interstitial lung disease.Considering the wide range of what is classified as ILD (ILD includes more than 150 diagnoses), the complexity of conducting studies to determine a given ILD prognosis, and the continuing changes in ILD classification, the role of PFTs in determining prognosis in ILD is complex. As mentioned above, physiologic abnormalities in ILD include low TLC, VC, and D
Many studies have been done to establish cutoff values to lead clinicians to better estimates of prognosis in ILD. Some of these studies have looked at absolute values at the time of diagnosis, and others have looked at a percent of decrease over time. The variables evaluated include FVC, D
In a recent retrospective report, Timmer and associates34 compared patients with IPF who died awaiting lung transplantation with those who did not. They found that PaO2 and FEV1:FVC were the only 2 variables that were significantly different between the 2 groups. In the recent ATS statement, determining prognosis in ILD was not listed as an indication to conduct the 6MWT31; however, there is some evidence that it can be a useful guide in determining the prognosis in patients awaiting lung transplantation, some of whom have ILD.35
Pulmonary hypertension.PFTs are not very helpful in predicting prognosis in primary PH. In the national registry for primary PH, D
In one study, PH patients who walked less than 300 m in 6 minutes had an increased likelihood of death or pretransplant hospital admission for continuous inotropic or mechanical support within 6 months.37 In another study, poor exercise capacity (less than 10% of the predicted value) identified patients who died during or soon after cardiac catheterization.8,38 Rhodes and coworkers38 reported that the ability of exercise testing to identify patients with primary PH who were at high risk for right heart catheterization was superior to that of other noninvasive variables.
The role of PFTs in clinical medicine continues to expand. The most important recent expansion is in screening smokers for the development of lung disease and the impact this may have on health care costs.
While PFTs have many benefits, they are expensive. If not indicated, PFTs can confuse the clinical picture and warrant unnecessary workups.39,40 It is therefore important to use them on evidence-based grounds and to understand what PFTs can-and cannot-tell you about your patients' health.
1. Zielinski J, Bednarek M, for the Know the Age of Your Lung Study Group. Early detection of COPD in a high-risk population using spirometric screening. Chest. 2001;119:731-736.
2. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994;272:1497-1505.
3. Coultas DB, Mapel D, Gagnon R, Lydick E. The health impact of undiagnosed airflow obstruction in a national sample of United States adults. Am J Respir Crit Care Med. 2001;164:372-377.
4. 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: 1146-1161.
5. American College of Physicians. Preoperative pulmonary function testing. Ann Intern Med. 1990;112: 793-794.
6. Powell CA, Caplan CE. Pulmonary function tests in preoperative pulmonary evaluation. Clin Chest Med. 2001;22:703-714, viii.
7. American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2002;96:485-496.
8. Waxman AB. Pulmonary function test abnormalities in pulmonary vascular disease and chronic heart failure. Clin Chest Med. 2001;22:751-758.
9. Thomas PS, Cowen ER, Hulands G, Milledge JS. Respiratory function in the morbidly obese before and after weight loss. Thorax. 1989;44:382-386.
10. Crapo RO. Pulmonary-function testing. N Engl J Med. 1994;331:25-30.
11. National Heart, Lung, and Blood Institute. New NHLBI guidelines for the diagnosis and management of asthma. Lippincott Health Promot Lett. 1997;2:1, 8-9.
12. Hunter CJ, Brightling CE, Woltmann G, et al. A comparison of the validity of different diagnostic tests in adults with asthma. Chest. 2002;121:1051-1057.
13. Goldstein MF, Pacana SM, Dvorin DJ, Dunsky EH. Retrospective analyses of methacholine inhalation challenges. Chest. 1994;105:1082-1088.
14. Alhamad EH, Lynch JP 3rd, Martinez FJ. Pulmonary function tests in interstitial lung disease: what role do they have? Clin Chest Med. 2001;22: 715-750, ix.
15. Epler GR, McLoud TC, Gaensler EA, et al. Normal chest roentgenograms in chronic diffuse infiltrative lung disease. N Engl J Med. 1978;298:934-939.
16. Rich S, Dantzker DR, Ayres SM, et al. Primary pulmonary hypertension. A national prospective study. Ann Intern Med. 1987;107:216-223.
17. Cressy DS, DeBoisblanc BP. Diagnosis and management of asthma: a summary of the National Asthma Education and Prevention Program guidelines. National Institutes of Health. J La State Med Soc. 1998;150:611-617.
18. Lange P, Parner J, Vestbo J, et al. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194-1200.
19. Cibella F, Cuttitta G, Bellia V, et al. Lung function decline in bronchial asthma. Chest. 2002;122: 1944-1948.
20. Turner MO, Noertjojo K, Vedal S, et al. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998;157:1804-1809.
21. Mitchell I, Tough SC, Semple LK, et al. Near-fatal asthma: a population-based study of risk factors. Chest. 2002;121:1407-1413.
22. Lee P, Abisheganaden J, Chee CB, Wang YT. A new asthma severity index: a predictor of near-fatal asthma? Eur Respir J. 2001;18:272-278.
23. Traver GA, Cline MG, Burrows B. Predictors of mortality in chronic obstructive pulmonary disease. A 15-year follow-up study. Am Rev Respir Dis. 1979;119: 895-902.
24. Hodgkin JE. Prognosis in chronic obstructive pulmonary disease. Clin Chest Med. 1990;11:555-569.
25. Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest. 2002; 121:1434-1440.
26. Crapo RO. Carbon monoxide diffusing capacity (transfer factor). Semin Respir Crit Care Med. 1998; 19:335-347.
27. Morrison NJ, Abboud RT, Ramadan F, et al. Comparison of carbon monoxide diffusing capacity and pressure-volume curves in detecting emphysema. Am Rev Respir Dis. 1989;139:1179-1187.
28. Gould GA, Redpath AT, Ryan M, et al. Lung CT density correlates with measurements of airflow limitation and the diffusing capacity. Eur Respir J. 1991;4:141-146.
29. American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152(5 pt 2):S77-S121.
30. Kessler R, Faller M, Fourgaut G, et al. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;159:158-164.
31. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166:111-117.
32. Doherty MJ, Pearson MG, O'Grady EA, et al. Cryptogenic fibrosing alveolitis with preserved lung volumes. Thorax. 1997;52:998-1002.
33. Hanson D, Winterbauer RH, Kirtland SH, Wu R. Changes in pulmonary function test results after 1 year of therapy as predictors of survival in patients with idiopathic pulmonary fibrosis. Chest. 1995;108: 305-310.
34. Timmer SJ, Karamzadeh AM, Yung GL, et al. Predicting survival of lung transplantation candidates with idiopathic interstitial pneumonia: does PaO2 predict survival? Chest. 2002;122:779-784.
35. Kadikar A, Maurer J, Kesten S. The six-minute walk test: a guide to assessment for lung transplantation. J Heart Lung Transplant. 1997;16:313-319.
36. D'Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med. 1991;115:343-349.
37. Cahalin LP, Mathier MA, Semigran MJ, et al. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest. 1996;110:325-332.
38. Rhodes J, Barst RJ, Garofano RP, et al. Hemodynamic correlates of exercise function in patients with primary pulmonary hypertension. J Am Coll Cardiol. 1991;18:1738-1744.
39. De Nino LA, Lawrence VA, Averyt EC, et al. Preoperative spirometry and laparotomy: blowing away dollars. Chest. 1997;111:1536-1541.
40. Chan B, Anderson G, Dales RE. Spirometry utilization in Ontario: practice patterns and policy implications. CMAJ. 1997;156:169-176.