Overview of Pulmonary Function Testing in Adults - UpToDate

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Visão geral dos testes de função pulmonar em adultos

Autor: David A. Kaminsky, MD
Editor de seção: Meredith C McCormack, MD, MHS
Editor Adjunto: Paul Dieffenbach, MD
Todos os tópicos são atualizados à medida que novas evidências se tornam disponíveis e nosso processo de
revisão por pares é concluído.
Revisão da literatura atual até: fevereiro de 2023. | Última atualização deste tópico: 07 de outubro de
2022.
INTRODUÇÃO
A avaliação da função pulmonar é importante em muitas situações clínicas, tanto quando o

paciente apresenta história ou sintomas sugestivos de doença pulmonar quanto quando
fatores de risco para doença pulmonar estão presentes, como exposição ocupacional a
agentes com toxicidade pulmonar conhecida [ 1 ] .
A European Respiratory Society e a American Thoracic Society publicaram diretrizes para a

medição e interpretação dos testes de função pulmonar (PFTs) [ 2-10 ].
Uma visão geral dos testes de função pulmonar será apresentada aqui, resumindo os tipos
de PFTs e suas indicações. Aspectos específicos dos testes de função pulmonar são
discutidos em outro lugar. (Consulte "Espirometria de consultório" e "Seleção de valores de
referência para testes de função pulmonar" e "Capacidade de difusão do monóxido de
carbono" e "Teste de função pulmonar na asma" e "Teste de broncoprovocação" e "Visão
geral dos testes de função pulmonar em crianças" .)
CONSELHOS RELACIONADOS COM A PANDEMIA DE COVID-19
A espirometria e outras manobras de teste de função pulmonar (PFT) podem promover

tosse e geração de aerossóis e podem levar à disseminação da doença de coronavírus 2019
(COVID-19; SARS-CoV-2) por pacientes infectados. É difícil rastrear pacientes para infecção
ativa por COVID-19, particularmente aqueles com sintomas respiratórios subjacentes, e
pacientes infectados, mas assintomáticos, podem disseminar o vírus. Assim, concordamos
com as recomendações dos especialistas de que a espirometria e outros PFTs sejam
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limitados a pacientes nos quais os resultados são essenciais para decisões imediatas de
tratamento [ 11 ]. O uso de nebulizadores para administrar broncodilatadores ou metacolina
para testes deve ser evitado.
As medidas para evitar a propagação do COVID-19 devem incluir higiene das mãos e
equipamentos de proteção individual (EPI; luvas, bata, máscara facial e escudo) para
funcionários e qualquer outra pessoa no espaço de teste (por exemplo, intérpretes).
Máscaras N95 ou respiradores purificadores de ar motorizados (PAPR) são preferíveis às
máscaras cirúrgicas. Os pacientes devem ser levados a uma sala de teste usando uma
abordagem que evite filas ou agrupamento de indivíduos em uma área de espera.
PFT equipment should be fitted with single-use mouthpieces and disposable in-line bacterial
and viral filters [12-14]. Enhanced cleaning of the testing area should be performed between
patients. Performance of PFTs can generate aerosol particles, potentially carrying infectious
virus, even when a filter is used [15]. Thus, it is preferred that negative pressure rooms with
at least six air exchanges per hour be used. Recognizing that the time needed for optimal
clearance of aerosol particles varies among laboratories, closure between patients is
recommended for 20 minutes to 3 hours (depending on ventilation of the particular space)
to enable clearance of respiratory aerosols [12-14]. A consensus statement has been
published for reference [16].
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).
● Holding bronchodilator medications – In preparation for PFTs, bronchodilator

medications are typically held so that bronchodilator response can be assessed after
baseline spirometry. As examples, short-acting inhaled beta agonists (eg, albuterol,
salbutamol) should not be used for four to six hours prior to testing [6]. The short-
acting muscarinic antagonist ipratropium should be held for 12 hours. Long-acting
beta agonist bronchodilators (eg, salmeterol, formoterol) should be held for 24 hours
prior to testing. The ultra-long-acting beta agonists (eg, indacaterol, olodaterol,
vilanterol) should be held for 36 hours, and the long-acting muscarinic antagonists
(also called anticholinergic agents) glycopyrrolate (glycopyrronium), tiotropium,
aclidinium, and umeclidinium should be held for 36 to 48 hours.
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 [6]. 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 [17]. The test takes 10 to 15 minutes and carries minimal risk (eg, rarely syncope).
The techniques for performing spirometry and interpretation of results are described
separately. (See "Office spirometry" and "Flow-volume loops".)
Spirometry is a key diagnostic test for asthma and chronic obstructive pulmonary disease
(COPD) when performed before and after bronchodilator and is useful to assess for asthma
or other causes of airflow obstruction in the evaluation of chronic cough. It is also used to
monitor a broad spectrum of respiratory diseases, including asthma, COPD, interstitial lung
disease, and neuromuscular diseases affecting respiratory muscles.
The slow vital capacity (SVC) can be measured as the maximal amount of air exhaled in a
relaxed expiration from full inspiration to residual volume; exhalation should be terminated
after 15 seconds [6]. The SVC may be a useful measurement when the FVC is reduced and
airway obstruction is present. Slow exhalation results in a lesser degree of airway narrowing,
and the patient may produce a larger, even normal vital capacity. In contrast, the vital
capacity with restrictive disease is reduced during both slow and fast maneuvers. Thus, if the
slow or forced vital capacity is within the normal range, it is generally unnecessary to
measure static lung volumes (residual volume and total lung capacity) [18].
Post-bronchodilator — Performance of spirometry before and after bronchodilator is used

to determine the degree of bronchodilator responsiveness. Administration of albuterol by
metered-dose inhaler (MDI) is indicated if baseline spirometry demonstrates airway
obstruction or if one suspects asthma or COPD. Albuterol or an equivalent short-acting beta
agonist is administered by MDI with a spacer or chamber device ( picture 1); proper MDI
technique is important to prevent false negative results [6]. Bronchodilator may also be
administered by nebulizer according to standard local practice. Spirometry should be
repeated 10 to 15 minutes after administration of a bronchodilator. (See "The use of inhaler
devices in adults".)
The European Respiratory Society/American Thoracic Society(ERS/ATS) interpretation

standards recommend that a significant bronchodilator response be defined by a greater
than or equal to increase in FEV1 or FVC by 10 percent of their respective predicted values
[3]. This is in contrast to the prior definition of an increase in the FEV1 or FVC of more than 12
percent and greater than 0.2 L [2]. This new definition is thought to be more accurate in
terms of avoiding age and size bias [19], is based on the upper limit of normal from
worldwide data [20], and is also associated with the important clinical outcome of mortality
[19].
In patients with asthma, bronchodilator administration often results in improvement, and in

some patients with asthma, post-bronchodilator testing may improve to normal spirometry
values. Among patients with COPD, administration of bronchodilator sometimes leads to a
significant change in FEV1 or FVC [21], but reversal to normal spirometry makes COPD less
likely [22]. Bronchodilators may also lead to improvement in flow in the small airways and a
reduction in air trapping. While criteria for assessment of reduced air trapping have not
been formalized, an increase in inspiratory capacity (IC) and a decrease in functional residual
capacity (FRC) are thought to reflect this response. (See 'Lung volumes' below.)
Sometimes, patients will note subjective improvements in their breathing after

bronchodilator inhalation, but without associated changes in FVC or FEV1 [23]. It is thought
that increased airflow within the tidal volume range, but not during deep inhalation, may
account for this discrepancy. Deep inhalations may be associated with airway narrowing,
which may offset the measured bronchodilator response. Thus, the lack of an acute
bronchodilator response on spirometry should not preclude a therapeutic trial of
bronchodilators and/or inhaled glucocorticoids, with reassessment of clinical status and
change in FEV1 at the end of that time [2].
Flow-volume loop — Flow-volume loops, which include forced inspiratory and expiratory
maneuvers, are always useful but especially whenever stridor is heard over the neck and
when evaluating unexplained dyspnea. Airway obstruction located in the pharynx, larynx, or
trachea (upper airways) is usually impossible to detect from standard expiratory FVC
maneuvers. Reproducible forced inspiratory vital capacity (FIVC) maneuvers may detect
variable extrathoracic upper airway obstruction [24], as can be seen with vocal fold paralysis
or dysfunction, which causes a characteristic limitation of flow (plateau) during forced
inhalation but little if any obstruction during exhalation ( figure 1). (See "Flow-volume
loops" and "Inducible laryngeal obstruction (paradoxical vocal fold motion)", section on
'Pulmonary function tests'.)
Less commonly, a fixed upper airway obstruction (UAO) (eg, tracheal stenosis) causes flow
limitation during both forced inhalation and forced exhalation maneuvers ( figure 1).
However, the flow-volume loop is not sensitive for detecting a fixed UAO, since the tracheal
lumen is often reduced to less than 1 cm before a plateau is recognized. Poor technique or
effort can mimic the flow-volume loop shapes of upper airway obstruction but are usually
excluded when three or more maneuvers are seen to be repeatable.
Bronchoprovocation challenge — Spirometry is used to assess the airway

hyperresponsiveness to a variety of bronchoprovocation challenges, such as methacholine,
mannitol, exercise, and isocapnic hyperpnea. Bronchoprovocation challenge is discussed

separately. (See "Bronchoprovocation testing".)
Supine and sitting spirometry — To evaluate respiratory muscle weakness, spirometry

can be obtained with the patient supine and sitting. Diaphragmatic weakness is suggested
by a decrease in the supine vital capacity (VC) >10 percent. Unilateral diaphragmatic paralysis
is usually associated with a decrease in VC of 15 to 25 percent; bilateral diaphragmatic
paralysis can be associated with a decrease in supine VC approaching 50 percent. (See
"Diagnostic evaluation of adults with bilateral diaphragm paralysis", section on 'Pulmonary
function tests' and "Diagnosis and management of nontraumatic unilateral diaphragmatic
paralysis (complete or partial) in adults", section on 'Pulmonary function testing'.)
Lung volumes — Measurement of lung volumes is important when spirometry shows a

decreased forced vital capacity. Body plethysmography is the gold standard for
measurement of lung volumes, particularly in the setting of airflow obstruction [5], although
lung volumes can be overestimated in the situation of severe airflow obstruction [25].
Alternative methods include helium dilution, nitrogen washout, and measurements based
on chest imaging. Helium dilution and nitrogen washout may underestimate lung volume in
patients with moderate to severe COPD because they do not access under- or nonventilated
areas.
Measurements of total lung capacity (TLC) using the chest radiograph or high-resolution
computed tomography (HRCT) correlate within 15 percent of those obtained by body
plethysmography [5,26]. Since the TLC is equivalent to the amount of air seen in the lungs on
a chest radiograph taken at maximal inspiration, it is important that the subject inhales
maximally as the image is created.
Common lung volume measurements include vital capacity, total lung capacity, functional
residual capacity, and residual volume. By convention, the term capacity is used for
compartments composed of two or more volumes. The relationships among the lung
volumes and capacities are shown in the figure ( figure 2) and listed below:
● Vital capacity (VC): maximum volume exhaled after maximum inspiration; can be
measured during forced exhalation (FVC) or slow exhalation (SVC)
● Functional residual capacity (FRC): volume of air remaining in chest at the end of a tidal
volume breath
● Residual volume (RV): volume of air remaining in chest after maximal exhalation
● Expiratory reserve volume (ERV): volume of air exhaled from end-tidal volume (FRC) to
point of maximal exhalation (RV), so RV plus ERV = FRC
● Inspiratory capacity (IC): maximum inspiration from end-tidal volume (FRC) to total lung
capacity
● Inspiratory reserve volume (IRV): volume of air inhaled during tidal breathing from end-
inhalation to total lung capacity
● Total lung capacity (TLC): volume of air in lungs at end of maximal inspiration (usually
calculated by RV plus VC or FRC plus IC)
A schema for the interpretation of PFT results is provided in the algorithm ( algorithm 1)
[3]. TLC is the key lung volume for determining restriction, defined as a TLC value less than
the 5th percentile of the predicted normal range (z-score <-1.645; roughly and imperfectly
approximated by values less than 80 percent of predicted); a reduced VC alone is not
sufficient evidence of restriction because it can be caused by air trapping due to severe
obstruction, neuromuscular weakness, or suboptimal effort [2].
Air trapping is indicated when the RV or RV/TLC is increased (>upper limit of normal [ULN]);
hyperinflation is indicated when the FRC and/or TLC are increased (>ULN). Thus, in the
setting of COPD with obstruction on spirometry and a low vital capacity, measurement of
lung volumes can help determine if there is a superimposed restrictive disorder or if VC is
decreased due to air trapping or hyperinflation.
The combination of an FEV1/FVC and TLC both less than the fifth percentile lower limit of
normal (LLN) is considered a mixed defect [3]. The combination of a normal FEV1/FVC and a
normal TLC and a low FEV1 or FVC is considered the nonspecific pattern [27]. The pattern in
which the FVC is disproportionately reduced relative to TLC has been described as the
complex restrictive pattern [28].
Maximal respiratory pressures — Measurement of maximal inspiratory and expiratory

pressures is indicated whenever there is an unexplained decrease in vital capacity or
respiratory muscle weakness is suspected clinically. Maximal inspiratory pressure (MIP),
measured near RV, is the maximal pressure that can be produced by the patient trying to
inhale through a blocked mouthpiece after a full exhalation. Maximal expiratory pressure
(MEP) is the maximal pressure measured during forced expiration (with cheeks bulging)
through a blocked mouthpiece after a nearly full inhalation to TLC. Repeated measurements
of MIP and MEP are useful in following the course of patients with neuromuscular disorders.
The slow vital capacity may also be followed, but it is less specific and usually less sensitive.
(See "Tests of respiratory muscle strength".)
Maximal inspiratory and expiratory pressures are easily measured using a simple
mechanical pressure gauge connected to a mouthpiece. MIP measures the ability of the
diaphragm and the other respiratory muscles to generate inspiratory force, reflected by a
negative airway pressure. The average MIP and MEP for adult men are -100 and +170 cm
H2O, respectively, while the corresponding values for adult women are approximately -70
and +110 cm H2O, respectively [29,30]. The LLN range is approximately two-thirds of these
values. (See "Tests of respiratory muscle strength", section on 'Interpretation (PImax, PEmax,
SNIP)'.)
Diffusing capacity — Measurement of the single-breath diffusing capacity for carbon

monoxide (DLCO; also known as transfer factor or TLCO) is quick, safe, and useful in the
evaluation of restrictive and obstructive lung disease, as well as pulmonary vascular disease.
The technique and interpretation are discussed separately [3,7,31]. (See "Diffusing capacity
for carbon monoxide", section on 'Methodology'.)
Interpretation of abnormal DLCO values differs based on any underlying concomitant

pulmonary process ( table 2). In the setting of restrictive disease, the diffusing capacity
helps distinguish between intrinsic lung disease, in which DLCO is usually reduced, and
other causes of restriction due to reduced lung volume, in which DLCO is often normal. In
the setting of obstructive disease, the DLCO helps distinguish between emphysema, in which
it is usually reduced, and other causes of chronic airway obstruction, like asthma or chronic
bronchitis, where it is usually normal. The DLCO is also used in the assessment of pulmonary
vascular disease (eg, thromboembolic disease, pulmonary hypertension), which typically
causes a reduction in DLCO in the absence of significant restriction or obstruction. (See
'Pulmonary vascular disease' below and "Diffusing capacity for carbon monoxide".)
GRADING PHYSIOLOGIC IMPAIRMENT
ERS/ATS interpretation standards emphasize that PFTs can only assess physiologic diagnoses
and not clinical ones. Similarly, the severity of lung disease cannot be determined by PFTs,
only the degree of physiologic impairment. Physiologic impairment should preferably be
assessed based on z-score, instead of percent predicted, because this scale helps avoid age,
sex, and height bias and is closely associated with important clinical outcomes [32,33].
FEV1 is the primary measure used to grade the physiologic severity of obstructive or mixed
obstructive-restrictive processes ( algorithm 2). We prefer to use TLC z-score to grade
severity of restriction; however, FEV1 may be used as an alternative to grade previously
confirmed restriction if lung volumes or z-scores are not available [2]. When using z-scores,
physiologic impairment severity (by FEV1, TLC, or DLCO) is graded as follows:
• Abnormally elevated – Z-score >1.645
• Normal – Z-score of -1.645 to 1.645
- In the setting of established obstruction (a reduced FEV1/FVC), an FEV1 in the

normal range still indicates a mild obstructive deficit.
• Mildly impaired – Z-score of -1.65 to -2.5
• Moderately impaired – Z-score of -2.5 to -4
• Severely impaired – Z-score <-4
A grading approach using percent of predicted normal values can be used as a nonpreferred
alternative when z-scores are not available ( algorithm 2 and table 3).
OTHER TESTING
Submaximal exercise testing — Submaximal exercise testing is often conducted in the

pulmonary function laboratory and does not require the resources needed for a maximal
cardiopulmonary exercise test [4,34]. Three commonly used submaximal tests are the six-
minute walk test, the incremental shuttle walk test, and the endurance shuttle walk test.
Cardiopulmonary exercise testing is discussed separately. (See "Cardiopulmonary exercise
testing in cardiovascular disease".)
Six-minute walk test — The six-minute walk test (6MWT) is a good index of physical
function and therapeutic response in patients with chronic lung disease, such as COPD,
pulmonary fibrosis, or pulmonary arterial hypertension [4,34-37]. The test should be
performed according to standard methods ( table 4) [4], including a practice walk to orient
the patient to the procedure. During a 6MWT, healthy subjects can typically walk 400 to 700
m [35,38]. In addition to total distance walked, the magnitude of desaturation and timing of
heart rate recovery have been associated with clinical outcomes.
Studies to understand meaningful changes in six-minute walk distances have been

conducted in several disease states. While there is some variability based on methods and
study population, the available evidence suggests an improvement of approximately 30 m in
distance walked is the minimally important difference (MID) [36,39-46]. While pulse oxygen
saturation and heart rate are recorded before and after the test, the 6MWT is not designed
to be an oxygen titration study, and a separate study should be performed to determine
supplemental oxygen needs.
Incremental shuttle walk test — The incremental shuttle walk test (ISWT) is a 12-level test
in which the subject walks at a progressively increasing speed for 12 minutes over a 10-
meter course, where each 10 m trip between cones is a "shuttle" [47-50]. Heart rate can be
monitored by pulse oximetry or telemetry [50]. The walking speed increases every minute
from an initial 0.5 m/sec to 2.37 m/sec at level 12. The test is stopped when the subject is
limited by dyspnea or heart rate (>85 percent predicted maximum), is unable to maintain the
required speed, or completes the 12 levels. The primary outcome is the distance covered,
which is calculated from the number of completed shuttles.
The distance walked in the ISWT depends on factors such as age, body mass index, FEV1,
quadriceps strength, and activity status, but reliable predictive equations for normal values
have not been developed [49]. As a rough estimate, healthy men were able to achieve the
following ISWT distances: age 40 to 49 years, 824 m; 50 to 59 years, 788 m; 60 to 69 years,
699 m; and 70 years and older, 633 m [49,51].
The validity of the ISWT was assessed in a systematic review, which found that the ISWT
distance correlated with peak oxygen uptake in subjects with COPD or cardiac disease (r
values ranged from 0.67 to 0.95) [47]. In addition, the ISWT distance walked was responsive
to pulmonary rehabilitation and bronchodilator administration. The minimal clinically
important distance in the ISWT in patients with COPD was 48 meters.
The ISWT is sometimes used as a screening test in the preoperative assessment of patients
for lung resection for lung cancer. An ISWT distance greater than 400 meters has been
associated with a maximum oxygen uptake (VO2 max) ≥15 mL/kg per minute [52], indicating
sufficient pulmonary reserve to tolerate lung resection surgery. (See "Preoperative
physiologic pulmonary evaluation for lung resection", section on 'Integrated
cardiopulmonary exercise testing'.)
Endurance shuttle walk test — In the endurance shuttle walk test (ESWT), the subject
walks at a constant speed between cones that are 10 meters apart [53]. The subject's speed
is selected to be approximately 85 percent of the maximal capacity measured from the ISWT,
so an ISWT is needed before the first ESWT [54]. During the ESWT, a pre-recorded audio
signal is used to communicate the target speed to the subject. Subjects walk until they are
too breathless, too tired, or no longer able to maintain the pace. Generally, the test is
stopped at 20 minutes, if the subject is still walking at that time. The primary measure is
total time walked with a minimal important difference of 65 seconds or 85 meters following
bronchodilation.
Pulse oxygen saturation — Assessment of oxygen saturation can be used to identify a gas
transfer defect and to titrate the amount of oxygen needed to maintain adequate
oxygenation. (See "Pulse oximetry" and "Long-term supplemental oxygen therapy".)
A clear consensus has not been reached about what value for resting oximetry differentiates
normal and abnormal. At sea level, values for pulse oxygen saturation (SpO2) ≤95 percent are
considered abnormal, although a decrease to 96 percent in a patient who has a previous
value of 100 percent could be abnormal. Exertional decreases in SpO2 ≥5 percentage points
are also considered abnormal. A value of SpO2 ≤88 percent is generally an indication for
supplemental oxygen, although the benefits of supplemental oxygen in patients with normal
resting saturations and exertional decreases to ≤88 percent are unclear [55]. Confirmation of
abnormal values with arterial blood gas (ABG) measurements may be indicated.
Arterial blood gases — ABGs are a helpful adjunct to pulmonary function testing in selected
patients. The primary role of measuring ABGs in stable outpatients is to confirm hypercapnia
when it is suspected on the basis of clinical history (eg, respiratory muscle weakness,
advanced COPD), an elevated serum bicarbonate level, and/or chronic hypoxemia. ABGs also
provide a more accurate assessment of the severity of gas exchange impairment in patients
who have low normal pulse oxygen saturation (eg, <92 percent) [56]. (See "Arterial blood
gases" and "Venous blood gases and other alternatives to arterial blood gases" and "Simple
and mixed acid-base disorders".)
CLINICAL USE OF PULMONARY FUNCTION TESTS
Pulmonary function testing is useful for evaluation of a variety of forms of lung disease or
for assessing the presence of disease in a patient with known risk factors, such as certain
rheumatic diseases and occupational exposure to agents with known lung toxicity. The
American Thoracic Society advises using a standard report format to improve
communication and understanding of test results ( figure 3) [17].
Indications — Indications for pulmonary function tests (PFTs) include ( table 1):
● Evaluation of symptoms such as chronic persistent cough, wheezing, dyspnea, and

exertional cough or chest pain
● Objective assessment of bronchodilator therapy
● Evaluation of effects of exposure to dusts or chemicals at work
● Risk evaluation of patients prior to thoracic or upper abdominal surgery
● Objective assessment of respiratory impairment
● Monitoring disease course and response to therapy
Chronic dyspnea — Many lung diseases begin slowly and insidiously and finally manifest
themselves with the nonspecific symptom of dyspnea on exertion. PFTs are an essential part
of the workup of such patients. In the outpatient setting, in which several days to weeks are
available to make the diagnosis, a cost efficient method of ordering PFTs is to start with
spirometry before and after a bronchodilator and then order further tests in a stepwise
fashion to refine the diagnosis ( algorithm 3). (See "Approach to the patient with
dyspnea".)
When a diagnosis is needed within a day or two, a full set of PFTs may be ordered, often
including spirometry before and after (pre- and post-) bronchodilator therapy, static lung
volumes, and diffusing capacity. If the cause of dyspnea on exertion remains uncertain after
these tests have been performed, cardiopulmonary exercise testing should be considered.
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Asthma — Spirometry before and after a bronchodilator is indicated during the initial
workup of patients suspected of having asthma ( algorithm 3). Spirometry is also indicated
during most follow-up office visits to provide an objective measure of asthma control [57].
(See 'Spirometry' above and "Asthma in adolescents and adults: Evaluation and diagnosis"
and "Pulmonary function testing in asthma".)
Cough or chest tightness with exercise or exposure to cold air, dusts, or fumes suggests
bronchial hyperresponsiveness (BHR). However, BHR may not be detected by pre- and post-
bronchodilator spirometry if the patient is asymptomatic at the time of evaluation.
Commonly, the patient is asked to return for retesting when symptoms occur; however, this
delays the diagnosis and may be impractical. Inhalation challenge testing can increase or
decrease the pretest probability of asthma in less than an hour. (See "Bronchoprovocation
testing" and "Exercise-induced bronchoconstriction".)
An alternative to inhalation challenge testing for the detection of airway hyperreactivity is

measurement of airway lability for two weeks in the patient's own environment, using
ambulatory monitoring of peak flow. Children with asthma (not controlled by medication)
typically demonstrate peak flow lability (amplitude/mean) in excess of 30 percent, while
adults with active asthma have peak expiratory flow (PEF) lability greater than 20 percent.
(See "Peak expiratory flow monitoring in asthma".)
A forced inspiratory maneuver performed as part of a flow-volume loop may be useful in

detecting inducible laryngeal obstruction, also known as vocal fold (or cord) dysfunction or
paradoxical vocal fold motion, in patients with a presentation suggestive of asthma who do
not respond appropriately to asthma therapy. (See "Evaluation of wheezing illnesses other
than asthma in adults" and "Inducible laryngeal obstruction (paradoxical vocal fold
motion)".)
Chronic obstructive pulmonary disease — Spirometry before and after an inhaled

bronchodilator administration is the best method to detect or confirm airways obstruction in
smokers with respiratory symptoms ( algorithm 3) [58,59].
In patients with chronic obstructive pulmonary disease (COPD), the forced expiratory volume
in one second/forced vital capacity (FEV1/FVC) ratio and the FEV1 are decreased. Repeating
spirometry after bronchodilator enables assessment of irreversible airflow limitation, which
is needed for the diagnosis of COPD. Traditionally, values below 70 percent for the FEV1/FVC
ratio and below 80 percent predicted for the FEV1 were used to define airflow obstruction.
However, several studies suggest that use of fixed thresholds leads to misclassification,
particularly in older adults where COPD can be falsely diagnosed [60,61]. Using the fifth
percentile lower limit of normal (LLN), or equivalently a z-score <1.645, instead of a fixed
value avoids this misdiagnosis of COPD in older adults, although some argue that the fixed
ratio of 0.7 has more clinical relevance [62]. The value for the post-bronchodilator FEV1 is
used to assess COPD severity. (See 'Post-bronchodilator' above and "Office spirometry",
section on 'Ratio of FEV1/FVC' and "Chronic obstructive pulmonary disease: Diagnosis and
staging", section on 'Diagnosis' and "Chronic obstructive pulmonary disease: Diagnosis and
staging", section on 'Assessment of severity and staging'.)
The FEV1/FVC ratio is typically the value reported and used to assess the presence of airflow
obstruction, although FEV1/slow vital capacity (FEV1/SVC) can also be used and may be more
sensitive in detecting airflow obstruction [3].
The gold standard for measurement of total lung capacity (TLC), particularly in the setting of
significant airflow obstruction, is body plethysmography. Other methods, such as helium
dilution and nitrogen washout, may underestimate the TLC in patients with moderate to
severe COPD. As noted above, lung volume measurement may identify air trapping or
hyperinflation caused by airflow limitation. A concomitant restrictive ventilatory defect is
detected in less than 10 percent of patients with a reduced FVC [63]. (See "Chronic
obstructive pulmonary disease: Diagnosis and staging".)
Once the diagnosis of COPD is established, the course and response to therapy may be
followed by observing changes in the FEV1, as was done in the multicenter Lung Health
Study [64]. Continued smoking in a patient with airways obstruction often results in an
abnormally rapid decline in FEV1 (90 to 150 mL/year). On the other hand, smoking cessation
often results in an increase in FEV1 during the first year, followed by a nearly normal rate of
FEV1 decline (20 to 30 mL/year) [65]. Both a low FEV1 and chronic mucus hypersecretion are
predictors of hospitalization due to COPD [66].
Once the airways obstruction due to COPD has become very severe, with an FEV1 z-score of
<-4, changes from visit to visit are usually within the error of the measurement (0.2 L). In this
circumstance, measurements of pulse oxygen saturation (SpO2) during exercise and distance
walked during six minutes may be more clinically meaningful for evaluating disease
progression or therapeutic response than are changes in spirometry values [4,67].
Measurement of the diffusing capacity for carbon monoxide (DLCO) helps to distinguish
between emphysema and other causes of chronic airway obstruction and has been shown to
improve assessment of patients with COPD [68]. As an example, emphysema lowers the
DLCO, obstructive chronic bronchitis does not affect the DLCO, and asthma sometimes
increases the DLCO. Changes in the DLCO in patients with established, smoking-related
COPD are probably not clinically useful during follow-up visits, unless dyspnea suddenly
worsens without an obvious cause. (See "Diffusing capacity for carbon monoxide".)
Upper airway obstruction — Intrathoracic upper airway obstruction can be either fixed (eg,
due to an airway stricture or goiter) or variable (eg, tracheomalacia, tracheal tumors). Fixed
intrathoracic obstruction is associated with reduced airflow during expiration and inspiration
with flattening of both limbs on the flow-volume loop ( figure 1). Variable intrathoracic
obstruction is associated with flow limitation during forced expiration, but not during
inhalation. (See "Flow-volume loops".)
Extrathoracic upper airway obstruction can also be fixed or variable. When fixed, the pattern
looks like fixed intrathoracic upper airway obstruction and flow is limited during inspiration
and expiration. When variable, the inspiratory portion of the loop shows flow limitation and
flattening ( figure 1). (See "Flow-volume loops", section on 'Abnormal inspiratory loop'.)
Restrictive ventilatory defect — The many disorders that cause reduction of lung volumes
(restriction) may be divided into three groups:
● Intrinsic lung diseases, which cause inflammation or scarring of the lung tissue
(interstitial lung disease) or fill the airspaces with exudate or debris (acute
pneumonitis)
● Extrinsic disorders, such as disorders of the chest wall or the pleura, which
mechanically compress the lungs or limit their expansion
● Neuromuscular disorders, which decrease the ability of the respiratory muscles to

inflate and deflate the lungs
The history, physical examination, and chest radiograph are usually helpful in distinguishing
among these disorders. Spirometry can be useful in detecting restriction of lung volumes,
meaning a reduced FEV1 and/or FVC with a normal or increased FEV1/FVC ratio. Evaluation of
lung volumes and diffusing capacity are helpful in confirming the presence of restriction and
assessing severity of impaired gas exchange ( algorithm 1). However, patients with mild
interstitial lung disease (ILD) may have normal values for FVC and TLC [69].
In ILD, the DLCO is decreased by diffuse alveolar capillary damage, and the measured
alveolar volume (VA) is low due to the loss of aerated alveoli. The DLCO divided by alveolar
volume (DLCO/VA, also known as KCO) is typically reduced to a lesser extent than the DLCO,
as ILD is typically inhomogeneous with some diversion of blood flow from more diseased
units to those that are less affected [31,70]. By comparison, in patients with restrictive
physiology due to incomplete lung expansion (eg, neuromuscular disease or kyphoscoliosis),
the DLCO is less decreased, and the reduction in DLCO is proportionately less than the
reduction in VA, so the ratio DLCO/VA is actually increased. (See "Diffusing capacity for
carbon monoxide", section on 'Relationship between DLCO and KCO (DLCO/VA)'.)
Changes in the FVC and DLCO are also useful for following the course of or response to
therapy in patients with interstitial lung disease. Measurement of SpO2 during a six-minute
walk test (6MWT) is also useful in this setting, since SpO2 often falls during mild exercise in
patients with interstitial lung disease and responds to successful therapeutic interventions
[71]. (See 'Six-minute walk test' above and "Approach to the adult with interstitial lung
disease: Diagnostic testing".)
Pulmonary vascular disease — In pulmonary vascular disease (eg, thromboembolic

disease or pulmonary arterial hypertension) not due to COPD or ILD, the DLCO is typically
reduced due to impairment of gas exchange at the alveolar-capillary interface. Testing for
desaturation with exercise oximetry can provide additional evidence of pulmonary vascular
disease. (See "Diffusing capacity for carbon monoxide", section on 'Interpretation'.)
Preoperative testing — Spirometry is useful for determining the risk of postoperative

pulmonary complications in certain high-risk situations, including patients known to have
COPD or asthma, current smokers, and those scheduled for thoracic or upper abdominal
surgery [72]. The degree of airways obstruction predicts the risk of postoperative pulmonary
complications, such as atelectasis, pneumonia, and the need for prolonged mechanical
ventilation. 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 glucocorticoids, and possibly antibiotics for bronchitis, will
reduce the risk. However, the results of spirometry alone should not be used to deny
surgery. Combining the results of spirometry with radioisotope or CT lung scans is also
useful for predicting the remaining lung function following a lobectomy or pneumonectomy.
(See "Evaluation of perioperative pulmonary risk", section on 'Preoperative risk assessment'
and "Preoperative physiologic pulmonary evaluation for lung resection".)
Evaluation of patients being considered for lung resection begins with spirometry and DLCO.
If either of these tests is ≤80 percent of predicted, further testing is generally needed to
calculate predicted postoperative lung function. A number of studies indicate that the
maximum oxygen uptake (absolute value, or as a percent of predicted), determined by
cardiopulmonary exercise testing, is better than spirometry for predicting postsurgical
complications [73], but the cost:benefit ratio is unknown. (See "Preoperative physiologic
pulmonary evaluation for lung resection".)
Respiratory impairment and disability assessment — Most schemes for evaluation of

respiratory impairment use spirometry and DLCO, but the results in studies performed at
rest are only a rough indication of an individual's ability to perform a given job. It is ideal to
measure maximal oxygen consumption (VO2 max), but cardiopulmonary exercise testing is
often not available to the primary care physicians who perform "disability" testing, or the
expense is not reimbursed. (See "Evaluation of pulmonary disability".)
The American Medical Association provides guidelines for the classification of respiratory
impairment based upon the results of clinical evaluation, spirometry, DLCO, and
cardiopulmonary exercise testing, if available. These guidelines are described separately.
(See "Evaluation of pulmonary disability", section on 'Calculating the permanent impairment

rating'.)
The Social Security Administration, Department of Veterans' Affairs in the United States, and
United States Department of Labor have slightly different criteria for assessment of
disability. (See "Evaluation of pulmonary disability" and "Evaluation of pulmonary disability",
section on 'Other systems'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pulmonary function
testing".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Breathing tests (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Overview – Pulmonary function testing is indicated for evaluation of respiratory

symptoms (eg, cough, wheezing, dyspnea, chest pain), response to bronchodilator
therapy, effect of workplace exposure to dust or chemicals, and pulmonary disability
( algorithm 3). It can also be used to assess severity and progression of lung
diseases, such as asthma, chronic obstructive lung disease, and various restrictive
diseases. (See 'Introduction' above.)
The major types of pulmonary function tests (PFTs) include spirometry, spirometry
before and after bronchodilator, lung volumes, and diffusing capacity ( table 1).
Other PFTs include flow-volume loops (which record forced inspiratory and expiratory
flow rates), measurements of maximal respiratory pressures, and the six-minute walk
test. (See 'Pulmonary function tests' above.)
● Spirometry – Forced expiratory volume in one second (FEV1) and forced vital capacity
(FVC) are the primary measurements obtained by spirometry ( algorithm 1). Their
ratio (FEV1/FVC) is important for distinguishing obstructive airways disease and
restrictive disease. A reduced ratio suggests obstructive airway disease. A reduced FVC
in combination with a normal or increased ratio suggests restrictive disease, if
accompanied by reduced lung volumes. (See 'Spirometry' above.)
● Flow-volume loops – Flow-volume loops with maximal inspiratory and expiratory data
can identify upper airway obstruction, which can be undetectable with standard
expiratory measurements. A characteristic limitation of flow (ie, a plateau) during
forced inhalation suggests variable extrathoracic obstruction, while limitation of flow
during forced exhalation suggests variable intrathoracic obstruction ( figure 1). Fixed
upper airway obstruction causes flow limitation during both forced inhalation and
forced exhalation. (See "Flow-volume loops".)
● Bronchodilator response – When airflow limitation is noted on spirometry or when

obstructive disease is suspected, the test is repeated after inhaled bronchodilator to
detect bronchodilator responsiveness. An increase in the FEV1 or FVC of more than 10
percent of their respective predicted values suggests bronchodilator responsiveness;
full return to normal values for FEV1 and FEV1/FVC suggests asthma. Partial
improvement is consistent with asthma, COPD, or bronchiolitis. The lack of a
bronchodilator response should not preclude a therapeutic trial of bronchodilators
and/or inhaled glucocorticoids. (See 'Post-bronchodilator' above.)
● Lung volumes – Measurement of lung volumes complements spirometry

( algorithm 1). Common measurements include total lung capacity (TLC), functional
residual capacity (FRC), and residual volume (RV) ( figure 2). Decreased lung volumes
suggest restrictive disease if accompanied by a normal or increased FEV1/FVC ratio.
Increased lung volumes suggest static hyperinflation due to obstructive airways
disease if accompanied by decreased FEV1/FVC ratio. Coexisting restriction and
obstruction can be identified when the TLC and FEV1/FVC ratio are reduced. (See 'Lung
volumes' above.)
● Tests of muscle strength – Measurement of maximal inspiratory and expiratory

pressures detects respiratory muscle weakness. Maximal inspiratory pressure (MIP) is
the maximal pressure that can be produced by the patient trying to inhale through a
blocked mouthpiece. Maximal expiratory pressure (MEP) is the maximal pressure

measured during forced expiration through a blocked mouthpiece after a full
inhalation. (See 'Maximal respiratory pressures' above and "Tests of respiratory muscle
strength".)
● Diffusing capacity of the lung for carbon monoxide (DLCO) – Measurement of DLCO
assesses gas exchange. A decreased DLCO accompanied by restrictive disease suggests
intrinsic lung disease, whereas a normal DLCO accompanied by restrictive disease
suggests a nonpulmonary cause of restriction. A decreased DLCO accompanied by
obstructive airways disease suggests emphysema. A reduced DLCO with normal lung
volumes suggests possible pulmonary vascular disease ( table 2). (See 'Diffusing
capacity' above and "Diffusing capacity for carbon monoxide".)
● Grading physiologic impairment – Physiologic impairment should preferably be

assessed based on z-score, instead of percent predicted value, because this scale helps
avoid age, sex, and height bias and is closely associated with important clinical
outcomes. FEV1 is the primary measure used to grade the physiologic severity of
obstructive or mixed obstructive-restrictive processes ( algorithm 2). We prefer to
use TLC z-score to grade severity of restriction; however, FEV1 may be used as an
alternative to grade previously confirmed restriction if lung volumes or z-scores are not
available.
● Submaximal exercise tests – Submaximal exercise testing can help in the evaluation
of dyspnea and exercise intolerance. Three commonly used tests are the six-minute
walk test (6MWT), the incremental shuttle walk test, and the endurance shuttle walk
test. The 6MWT provides information about the distance walked and exertional
desaturation when combined with pulse oximetry ( table 4). (See 'Submaximal
exercise testing' above.)
● Pulse oxygen saturation (SpO2) – Assessment of SpO2 at rest or with exertion can be
used to identify a gas exchange defect and to titrate the amount of oxygen needed to
maintain adequate oxygenation. A clear consensus has not been reached about the
value for resting oximetry that differentiates normal and abnormal. At sea level, values
for SpO2 ≤95 percent are generally considered abnormal, although a decrease to 96
percent in a patient who has a previous value of 100 percent could be abnormal.
Exertional decreases in SpO2 ≥5 percentage points are also considered abnormal. (See
'Pulse oxygen saturation' above and "Pulse oximetry".)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Paul Enright, MD, who contributed to earlier
versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
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Topic 6969 Version 33.0
GRAPHICS
Seleção de testes de função pulmonar
Exames a serem
Contexto solicitados na maioria Teste avançado
dos pacientes
Dispnéia em repouso ou em Espirometria antes e depois do Teste de exercício

esforço broncodilatador cardiopulmonar
volumes pulmonares
DLCO
Oximetria ambulatorial com

subida de escada
Tosse Espirometria antes e depois do Bronchoprovocation challenge

broncodilatador testing if spirometry normal
and asthma suspected
Asthma Spirometry before and after Bronchoprovocation challenge

bronchodilator testing if spirometry normal
and asthma suspected
COPD Spirometry before and after Lung volumes (can be ordered

bronchodilator if FVC is low, chest radiograph
shows hyperinflation, dyspnea
Oximetry at rest
is out of proportion to
spirometric abnormalities)
DLCO (can be ordered with

initial spirometry or after
irreversible airflow obstruction
is identified)
Ambulatory oximetry if resting

oximetry is <95%
Oximetry during sleep (to

check adequacy of
supplemental oxygen or in
patients with awake, resting
SpO 2 <92%)
Suspected bronchiectasis Spirometry before and after

bronchodilator
Lung volumes
Suspected bronchiolitis Spirometry before and after

bronchodilator
Lung volumes
DLCO
Suspected upper airway Spirometry with flow volume

obstruction (eg, stridor, loop (look at shape of curves)
hoarseness and dyspnea,
unexplained dyspnea)
Suspected ILD (eg, Spirometry Cardiopulmonary exercise test

hypersensitivity pneumonitis, may be used in evaluation for
Lung volumes
sarcoidosis, idiopathic lung transplantation
pulmonary fibrosis, or DLCO
abnormal chest radiograph) Oximetry at rest
Ambulatory oximetry or six-

minute walk test
Suspected neuromuscular or Spirometry Arterial blood gas if FVC <1 L

chest wall disease
Lung volumes
Maximal inspiratory force
Maximal expiratory force
Suspected diaphragmatic Spirometry upright and supine

weakness
Lung volumes
Maximal inspiratory force
Maximal expiratory force
DLCO: diffusing capacity for carbon monoxide; COPD: chronic obstructive pulmonary disease;
FVC: forced vital capacity; ILD: interstitial lung disease.
Graphic 106178 Version 3.0
Spacer devices
A variety of spacer devices are available to enhance the delivery of

aerosolized medications to distal areas of the lung and limit
systemic absorption.
Flow-volume loops in upper airway obstruction
The configuration of the flow-volume loop can help distinguish the site of airway narrowing. The
airways are divided into intrathoracic and extrathoracic components by the thoracic inlet.
(A) Normal flow-volume loop: the expiratory portion of the flow-volume curve is characterized by a
rapid rise to the peak flow rate, followed by a nearly linear fall in flow. The inspiratory curve is a
relatively symmetrical, saddle-shaped curve.
(B) Dynamic (or variable, nonfixed) extrathoracic obstruction: flow limitation and flattening are noted
on the inspiratory limb of the loop.
(C) Dynamic (or variable, nonfixed) intrathoracic obstruction: flow limitation and flattening are noted
on the expiratory limb of the loop.
(D) Fixed upper airway obstruction (can be intrathoracic or extrathoracic): flow limitation and
flattening are noted in both the inspiratory and expiratory limbs of the flow-volume loop.
(E) Peripheral or lower airways obstruction: expiratory limb demonstrates concave upward, also called
"scooped-out" or "coved" pattern.
TLC: total lung capacity; RV: residual volume.
Adapted from: Stoller JK. Spirometry: a key diagnostic test in pulmonary medicine. Cleve Clin J Med 1992; 59:75.
Pulmonary function tests: Lung volumes and

capacities
These are boundaries of lung volume within which tidal volume can
vary. A lung capacity is a combination of more than one lung
volume. TLC, for example, is the combination of FRC plus IC (or the
combination of RV, ERV, VT, and IRV). TLC, RV, and their ratio provide
the most information about restrictive lung disease and help
differentiate between restrictive and obstructive disorders. However,
TLC and RV are effort-dependent, so an evaluation of strength
and/or effort is needed. In contrast, the FRC is effort-independent.
IRV: inspiratory reserve volume; VT: tidal volume; ERV: expiratory

reserve volume; RV: residual volume; IC: inspiratory capacity; FRC:
functional residual capacity; TLC: total lung capacity; VC: vital
capacity.
Algorithm for pulmonary function test interpretation
COPD: chronic obstructive pulmonary disease; DLCO: diffusing capacity for carbon monoxide; FEV 1 : forc
volume in one second; FVC: forced vital capacity; VC: vital capacity; ILD: interstitial lung disease.
* Bronchoprovocation testing uses a variety of challenges (eg, methacholine, mannitol, exercise, isocapn
to assess airway hyperresponsiveness.
¶ Causes of high DLCO include increased hemoglobin and increased pulmonary vascular blood volume (
shunt, asthma, and obesity).
Interpretation of diffusing capacity of the lungs for carbon monoxide

(DLCO)
Increased DLCO
Altitude
Asthma
Polycythemia
Severe obesity
Pulmonary hemorrhage
Left-to-right intracardiac shunting
Mild left heart failure - increased pulmonary capillary blood volume
Exercise just prior to the test - increased cardiac output
Mueller maneuver
Supine position
Low DLCO with normal spirometry and normal lung volume
Anemia - mild decrease
Pulmonary vascular disease - mild to severe decrease
Early interstitial lung disease - mild to moderate decrease
Valsalva maneuver
Low DLCO with obstruction with or without concomitant restriction

Bronchiolitis
Combined pulmonary fibrosis and emphysema (CPFE)
Cystic fibrosis
Emphysema
Interstitial lung disease in patient with COPD
Lymphangioleiomyomatosis
Sarcoid
Low DLCO with restriction

Interstitial lung disease
Pneumonitis
Other
Carboxyhemoglobin - reduces DLCO
Supplemental oxygen - reduces DLCO
Bronchodilator - increases DLCO
Classification and grading of ventilatory impairments based on spirometry [1
FEV 1 : forced expiratory volume in one second; FVC: forced vital capacity; LLN: lower limit of normal, the
5th percentile.
* Low refers to levels below the 5th percentile, or a z-score <–1.645; absolute values are not used due to
changes in spirometry with age and other factors.
¶ A reduced FVC does not prove a restrictive process. Confirmation of restriction requires evaluation of
lung volumes in a pulmonary function laboratory (ie, total lung capacity z-score <–1.645 or below fifth
percentile).
Δ A reduced FVC with normal FEV 1 /FVC and lung-volumes is a "nonspecific" pattern that may be followed
over time. One-third of patients with nonspecific patterns develop obstructive or restrictive disease in th
next three years.
◊ Many patients with reduced FEV 1 /FVC and low FVC have simple obstruction with air-trapping or failure
to complete exhalation.
§ The severity of obstructive and mixed obstructive/restrictive ventilatory impairments are physiological
graded by decrement in FEV 1 . Patients with restriction should have restrictive impairment confirmed an
graded based on total lung capacity, but may be monitored by changes in FEV 1 . FEV 1 may also be used
as an alternative method to grade severity of confirmed restriction when only spirometry or % predicted
values are available.
¥ Z-score is the preferred method for grading severity based on 2022 European Respiratory
Society/American Thoracic Society (ERS/ATS) guidelines because it reduces bias due to age, sex, and othe
factors. Some spirometry software continues to report percent predicted, so we also include
categorization based on this reporting method. The percent predicted severity classification has been
adapted from earlier guidelines and modernized by reducing the number of distinct categories.
References:
1. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine lung function
tests. Eur Respir J 2022; 60:2101499.
2. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948.
Severity classification of diffusing capacity of the lungs for carbon

monoxide (DLCO) [1]
DLCO (Z-score not

DLCO (preferred scale)* Diffusion abnormality
available)
Z-score >1.645 Abnormally high DLCO >140% predicted
Z-score –1.645 to 1.645 Normal DLCO 76 to 140% predicted
Z-score –1.65 to –2.5 Mild impairment DLCO 61 to 75% predicted
Z-score –2.5 to –4.0 Moderate impairment DLCO 41 to 60% predicted
Z-score <–4.0 Severe impairment DLCO <40% predicted
* The Z-score represents the normal distribution in healthy individuals taking into account
reference equation parameters (eg, age, sex, height). A Z-score of 1.645 represents the upper
limit of normal (95th percentile) and a Z-score of -1.645 represents the lower limit of normal (5th
percentile). Z-score is recommended for severity grading to standardize measurement and
reduce bias due to age, sex, and other factors. Some pulmonary function laboratories may still
report using percent of predicted value; one grading scale for this measure is included.
Reference:
1. Stanojevic S, Kaminsky D, Miller M, et al. ERS/ATS technical standard on interpretive strategies for routine lung
function tests. Eur Respir J 2022; 60:2101499.
Six-minute walk test technique [2,3]
Flat, straight corridor 30 m (100 feet) in length
Turnaround points marked with a cone
Patient should wear comfortable clothes and shoes
Patient rests in chair for at least 10 minutes prior to test (ie, no warm-up period)
Heart rate and pulse oxygen saturation (SpO 2 ) should be monitored throughout the test
If the patient is using supplemental oxygen, record the flow rate and type of device
Have patient stand and rate baseline dyspnea and overall fatigue using Borg scale* [1]
Set lap counter to zero and timer to six minutes
Instruct the patient: Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes,
but don't run or jog. Pivot briskly around the cone.
Standardized encouragement statements should be provided at one minute intervals, such as

"You are doing well. You have _ minutes to go" and "Keep up the good work. You have _
minutes to go."
At the end of the test, mark the spot where the patient stopped on the floor
If using a pulse oximeter, measure the pulse rate and SpO 2 and record
After the test record the Borg* [1] dyspnea and fatigue levels
Ask, "What, if anything, kept you from walking farther?"
Calculate the distance walked and record
* Refer to UpToDate table on the modified Borg Scale.
Reference:
1. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14:377.
2. American Thoracic Society. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;
166:111.
3. 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.
Sample pulmonary function test report
Example of a single-page report for pre- and postbronchodilator spirometry testing. The linear graphic is
divided in units of 1 SD, with the LLN shown at a z-score of –1.64. This simplified report is suitable for the
medical record or referring physician, but the test interpreter should have access to the data and curves
all acceptable spirometry efforts.
SpO 2 : oxygen saturation as measured by pulse oximetry; LLN: lower limit of normal; FVC: forced vital
capacity; FEV 1 : forced expiratory volume in one second; FET: forced expiratory time; GLI: Global Lung
Function Initiative; ULN: upper limit of normal; VC: vital capacity; IC: inspiratory capacity; SD: standard
deviation.
Reprinted with permission of the American Thoracic Society. Copyright © 2018 American Thoracic Society. Culver BH, Graham BL,
Coates AL, et al. Recommendations for a Standardized Pulmonary Function Report. An Official American Thoracic Society Technic
Statement. Am J Respir Crit Care Med 2017; 196:1463-1472. The American Journal of Respiratory and Critical Care Medicine is an
official journal of the American Thoracic Society.
Abordagem para seleção de PFTs em um paciente com

dispneia
Um método passo a passo eficiente para determinar a causa da dispneia

crônica usando testes de função pulmonar.
VEF 1 : volume expiratório forçado no primeiro segundo; CVF: capacidade

vital forçada; CV: capacidade vital; DLCO: capacidade de difusão; WNL:
dentro dos limites normais; DPOC: doença pulmonar obstrutiva crônica;
PImáx: pressão inspiratória máxima; PEmáx: pressão expiratória máxima.
Gráfico 67095 Versão 5.0
Contributor Disclosures
David A Kaminsky, MD Other Financial Interest: MGC Diagnostics Inc [Speaker/faculty
cardiorespiratory diagnostics course]. All of the relevant financial relationships listed have been
mitigated. Meredith C McCormack, MD, MHS Consultant/Advisory Boards: Aridis [Pulmonary function
testing];Boehringer Ingelheim[COPD and asthma];Celgene [Asthma];GlaxoSmithKline [Chronic
obstructive pulmonary disease]. All of the relevant financial relationships listed have been
mitigated. Paul Dieffenbach, MD No relevant financial relationship(s) with ineligible companies to
disclose.
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em vários níveis e por meio de requisitos para referências a serem fornecidas para apoiar o conteúdo.
O conteúdo devidamente referenciado é exigido de todos os autores e deve estar em conformidade
com os padrões de evidência do UpToDate.
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31/03/2023, 18:14 Overview of pulmonary function testing in adults - UpToDate

Reimpressão oficial do UpToDate ®

Visão geral dos testes de função pulmonar em adultos

A avaliação da função pulmonar é importante em muitas situações clínicas, tanto quando o

A European Respiratory Society e a American Thoracic Society publicaram diretrizes para a

CONSELHOS RELACIONADOS COM A PANDEMIA DE COVID-19

A espirometria e outras manobras de teste de função pulmonar (PFT) podem promover

PULMONARY FUNCTION TESTS

● Holding bronchodilator medications – In preparation for PFTs, bronchodilator

Post-bronchodilator — Performance of spirometry before and after bronchodilator is used

The European Respiratory Society/American Thoracic Society(ERS/ATS) interpretation

In patients with asthma, bronchodilator administration often results in improvement, and in

Sometimes, patients will note subjective improvements in their breathing after

Bronchoprovocation challenge — Spirometry is used to assess the airway

mannitol, exercise, and isocapnic hyperpnea. Bronchoprovocation challenge is discussed

Supine and sitting spirometry — To evaluate respiratory muscle weakness, spirometry

Lung volumes — Measurement of lung volumes is important when spirometry shows a

Maximal respiratory pressures — Measurement of maximal inspiratory and expiratory

Diffusing capacity — Measurement of the single-breath diffusing capacity for carbon

Interpretation of abnormal DLCO values differs based on any underlying concomitant

GRADING PHYSIOLOGIC IMPAIRMENT

• Abnormally elevated – Z-score >1.645

• Normal – Z-score of -1.645 to 1.645

- In the setting of established obstruction (a reduced FEV1/FVC), an FEV1 in the

• Mildly impaired – Z-score of -1.65 to -2.5

• Moderately impaired – Z-score of -2.5 to -4

• Severely impaired – Z-score <-4

Submaximal exercise testing — Submaximal exercise testing is often conducted in the

Studies to understand meaningful changes in six-minute walk distances have been

CLINICAL USE OF PULMONARY FUNCTION TESTS

● Evaluation of symptoms such as chronic persistent cough, wheezing, dyspnea, and

An alternative to inhalation challenge testing for the detection of airway hyperreactivity is

A forced inspiratory maneuver performed as part of a flow-volume loop may be useful in

Chronic obstructive pulmonary disease — Spirometry before and after an inhaled

● Neuromuscular disorders, which decrease the ability of the respiratory muscles to

Pulmonary vascular disease — In pulmonary vascular disease (eg, thromboembolic

Preoperative testing — Spirometry is useful for determining the risk of postoperative

Respiratory impairment and disability assessment — Most schemes for evaluation of

(See "Evaluation of pulmonary disability", section on 'Calculating the permanent impairment

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Breathing tests (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Overview – Pulmonary function testing is indicated for evaluation of respiratory

● Bronchodilator response – When airflow limitation is noted on spirometry or when

● Lung volumes – Measurement of lung volumes complements spirometry

● Tests of muscle strength – Measurement of maximal inspiratory and expiratory

blocked mouthpiece. Maximal expiratory pressure (MEP) is the maximal pressure

● Grading physiologic impairment – Physiologic impairment should preferably be

Use of UpToDate is subject to the Terms of Use.

1. Crapo RO. Pulmonary-function testing. N Engl J Med 1994; 331:25.

5. Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung

6. Graham BL, Steenbruggen I, Miller MR, et al. Standardization of Spirometry 2019

10. Laveneziana P, Albuquerque A, Aliverti A, et al. ERS statement on respiratory muscle

13. Recommendation from ERS Group 9.1 (Respiratory function technologists/Scientists): Lu

16. McGowan A, Laveneziana P, Bayat S, et al. International consensus on lung function

Anesth Analg 2007; 105:S18.

Seleção de testes de função pulmonar

Dispnéia em repouso ou em Espirometria antes e depois do Teste de exercício

Oximetria ambulatorial com

Tosse Espirometria antes e depois do Bronchoprovocation challenge

Asthma Spirometry before and after Bronchoprovocation challenge

COPD Spirometry before and after Lung volumes (can be ordered