What is the term for the maximum volume of air that can be expired when the patient exhales as forcefully and rapidly as possible and for as long as possible?

Quantitative measures of inspiratory and expiratory flow are obtained by forced spirometry. Nose clips are used to occlude the nares.

In expiratory flow assessments, patients inhale as deeply as possible, seal their lips around a mouthpiece, and exhale as forcefully and completely as possible into an apparatus that records the exhaled volume (forced vital capacity [FVC]) and the volume exhaled in the first second (the forced expiratory volume in 1 second [FEV1]—see figure Normal spirogram Normal spirogram

In inspiratory flow and volume assessments, patients exhale as completely as possible, then forcibly inhale.

These maneuvers provide several measures:

• FVC: Maximal amount of air that the patient can forcibly exhale after taking a maximal inhalation

• FEV1: Volume exhaled in the first second

• Peak expiratory flow (PEF): Maximal speed of airflow as the patient exhales

FEV1 and FVC help differentiate obstructive and restrictive lung disorders. A normal FEV1 makes irreversible obstructive lung disease unlikely whereas a normal FVC makes restrictive disease unlikely.

Normal spirogram

FEF25–75% = forced expiratory flow during expiration of 25 to 75% of the FVC; FEV1 = forced expiratory volume in the first second of forced vital capacity maneuver; FVC = forced vital capacity (the maximum amount of air forcibly expired after maximum inspiration).

The forced expiratory flow averaged over the time during which 25 to 75% of the FVC is exhaled may be a more sensitive marker of mild, small airway airflow limitation than the FEV1, but the reproducibility of this variable is poor.

Interpretation of these measures depends on good patient effort, which is often improved by coaching during the actual maneuver. Acceptable spirograms demonstrate

• Good test initiation (eg, a quick and forceful onset of exhalation)

• No coughing

• Smooth curves

• Absence of early termination of expiration (eg, minimum exhalation time of 6 seconds with no change in volume for the last 1 second)

Reproducible efforts agree within 5% or 100 mL with other efforts. Results not meeting these minimum acceptable criteria should be interpreted with caution.

Lung volumes are measured by determining functional residual capacity (FRC). FRC is the amount of air remaining in the lungs after normal exhalation. The total lung capacity (TLC) is the volume of gas that is contained in the lungs at the end of maximal inspiration.

Normal lung volumes

ERV = expiratory reserve volume; FRC = functional residual capacity; IC = inspiratory capacity; IRV = inspiratory reserve volume; RV = residual volume; TLC = total lung capacity; VC = vital capacity; VT= tidal volume.

FRC = RV + ERV; IC = VT + IRV; VC = VT+ IRV + ERV.

FRC is measured using gas dilution techniques or a plethysmograph (which is more accurate in patients who have airflow limitation and trapped gas).

Gas dilution techniques include

• Nitrogen washout

• Helium equilibration

With nitrogen washout, the patient exhales to FRC and then breathes from a spirometer containing 100% oxygen. The test ends when the exhaled nitrogen concentration is zero. The collected volume of exhaled nitrogen is equal to 81% of the initial FRC.

With helium equilibration, the patient exhales to FRC and then is connected to a closed system containing known volumes of helium and oxygen. Helium concentration is measured until it is the same on inhalation and exhalation, indicating it has equilibrated with the volume of gas in the lung, which can then be estimated from the change in helium concentration that has occurred.

Both of these techniques may underestimate FRC because they measure only the lung volume that communicates with the airways. In patients with severe airflow limitation, a considerable volume of trapped gas may communicate very poorly or not at all.

Body plethysmography uses Boyle’s law to measure the compressible gas volume within the thorax and is more accurate than gas dilution techniques. While sitting in an airtight box, the patient tries to inhale against a closed mouthpiece from FRC. As the chest wall expands, the pressure in the closed box rises. Knowing the pre-inspiratory box volume and the pressure in the box before and after the inspiratory effort allows for calculation of the change in box volume, which must equal the change in lung volume.

Knowing FRC allows the lungs to be divided into subvolumes that are either measured with spirometry or calculated (see figure Normal lung volumes Normal lung volumes

In contrast to the spirogram, which displays airflow (in L) over time (in seconds), the flow-volume loop displays airflow (in L/second) as it relates to lung volume (in L) during maximal inspiration from complete exhalation (residual volume [RV]) and during maximum expiration from complete inhalation (TLC). The principal advantage of the flow-volume loop is that it can show whether airflow is appropriate for a particular lung volume. For example, airflow is normally slower at low lung volumes because elastic recoil is lower at lower lung volumes. Patients with pulmonary fibrosis have low lung volumes and their airflow appears to be decreased if measured alone. However, when airflow is presented as a function of lung volume, it becomes apparent that airflow is actually higher than normal (as a result of the increased elastic recoil characteristic of fibrotic lungs).

Flow-volume loops

(A) Normal. Inspiratory limb of loop is symmetric and convex. Expiratory limb is linear. Airflow at the midpoint of inspiratory capacity and airflow at the midpoint of expiratory capacity are often measured and compared. Maximal inspiratory airflow at 50% of forced vital capacity (MIF 50% FVC) is greater than maximal expiratory airflow at 50% FVC (MEF 50% FVC) because dynamic compression of the airways occurs during exhalation.

(B) Obstructive disorder (eg, emphysema, asthma). Although all airflow is diminished, expiratory prolongation predominates, and MEF < MIF. Peak expiratory flow is sometimes used to estimate degree of airway obstruction but depends on patient effort.

(C) Restrictive disorder (eg, interstitial lung disease, kyphoscoliosis). The loop is narrowed because of diminished lung volumes. Airflow is greater than normal at comparable lung volumes because the increased elastic recoil of lungs holds the airways open.

(D) Fixed obstruction of the upper airway (eg, tracheal stenosis, goiter). The top and bottom of the loops are flattened so that the configuration approaches that of a rectangle. Fixed obstruction limits flow equally during inspiration and expiration, and MEF = MIF.

(E) Variable extrathoracic obstruction (eg, unilateral vocal cord paralysis, vocal cord dysfunction). When a single vocal cord is paralyzed, it moves passively with pressure gradients across the glottis. During forced inspiration, it is drawn inward, resulting in a plateau of decreased inspiratory flow. During forced expiration, it is passively blown aside, and expiratory flow is unimpaired. Therefore, MIF 50% FVC < MEF 50% FVC.

(F) Variable intrathoracic obstruction (eg, tracheomalacia). During a forced inspiration, negative pleural pressure holds the floppy trachea open. With forced expiration, loss of structural support results in tracheal narrowing and a plateau of diminished flow. Airflow is maintained briefly before airway compression occurs.

FVC = forced vital capacity; MEF = maximal expiratory flow; MIF = maximal inspiratory flow; PEF = peak expiratory flow; RV = residual volume; TLC = total lung capacity.

Flow-volume loops require that absolute lung volumes be measured. Unfortunately, many laboratories simply plot airflow against the FVC; the flow-FVC loop does not have an inspiratory limb and therefore does not provide as much information.

• Increased resistance to airflow due to abnormalities within the airway lumen (eg, tumors, secretions, mucosal thickening)

• Changes in the wall of the airway (eg, contraction of smooth muscle, edema)

• Decreased elastic recoil (eg, the parenchymal destruction that occurs in emphysema)

With decreased airflow, expiratory times are longer than usual, and air may become trapped in the lungs due to incomplete emptying, thereby increasing lung volumes (eg, TLC, RV).

Eucapnic voluntary hyperventilation (EVH) may also be used to diagnose exercised-induced bronchoconstriction. EVH involves hyperventilation of a gas mixture of 5% carbon dioxide and 21% oxygen at 85% of maximum voluntary ventilation for 6 minutes. FEV1 is then measured at specified intervals after the test. As with other bronchial provocation tests, the drop in FEV1 that is diagnostic of exercise-induced bronchospasm varies by laboratory.

Restrictive disorders are characterized by a reduction in lung volume, specifically a TLC < 80% of the predicted value. However, in early restrictive disease, the TLC can be normal (as a result of strong inspiratory effort) and the only abnormality might be a reduction in RV. The decrease in TLC determines the severity of restriction (see table ). The decrease in lung volumes causes a decrease in airflow (reduced FEV1—see figure ). However, airflow relative to lung volume is increased, so the FEV1/FVC ratio is normal or increased.

Restrictive defects are caused by the following:

• Loss in lung volume (eg, lobectomy)

• Abnormalities of structures surrounding the lung (eg, pleural disorder, kyphosis, obesity)

• Weakness of the inspiratory muscles of respiration (eg, neuromuscular disorders)

The feature common to all is a decrease in the compliance of the lungs, the chest wall, or both.