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Lung Function Test: Basics & Interpretation #2

May 29 | 5:30 AM

PFTs are typically interpreted by comparing data collected in a single patient or subject to reference (predicted) values based on healthy participants. Predicted values should come from studies of normal or healthy persons with similar anthropometric characteristics. Lung volumes, spirometry and flow volume loops, and diffusing capacity are all components of PFTs. PFTs are commonly requested to: Look for indications of respiratory disease when patients report with respiratory symptoms (e.g. dyspnea, cough, cyanosis, wheezing, etc.), Assess for lung disease progression, monitor the efficacy of a specific treatment, and so on. Let's learn the fundamentals of PFT with Dr. Salil Bendre, a famous Medflix select faculty. This session is continuation of part-1 session on PFT.

[Music] i dr rucha welcome you all on behalf of team netflix uh we have an amazing faculty back with us for hashtag two pft session uh we did a pft fun uh session on 15th of may i'm going to go back to replay section and watch the recording and today uh sir will be continuing on that part uh sir consultant chess physician and pulmonologist practicing at global massena hospital mumbai uh welcome sir we are looking forward to this session good morning okay thank you dr and good morning friends so today we are going to go ahead with the next uh aspect or we are going to continue with the understanding and learning uh lung function test or what is called as the spirometry so you know when we commonly use the term lung function test it implies the functioning of the lung so let's first let me make things clear that lung function test is a broad term for many investigations by which we can measure the lung functions and one of them is a spirometry so what we are discussing actually last time also and today is the terminology of spirometric because if we talk of a lung function test then it can even be a six minute walk test which can assess the functioning of the lung a arterial blood gas which is a abg can assess the function of the lungs cardiopulmonary exercise testing can assess the function of the lungs so there is there are many aspects to what is what is included in a lung function test but we are going to discuss today like last time spirometry and since we are discussing spirometry we have to go back to this basic diagram so five minutes i'm going to spend on what we had discussed last time and for all those who have been with me for the last lecture also in today's lecture it may be a little uh easy for you to understand but i am sure that all of you will have to read to visu to go through the replay of the previous one too to really comprehend these lung functions and these values okay so spirometry uh means we are going to measure the lung volumes we are going to measure the lung capacity and we are going to know whether the volume is improving after the bronchodilator or no why do we want to know this we had discussed that we want to distribute or break down the lung disease into a restrictive lung disease and obstructive lung disease because both these diseases may be restrictive may be obstructive they will come with a common complaint of breathing difficulty so once they come with a breathing difficulty not everyone will benefit with bronchodilators not everyone will benefit with steroids so you need to actually know whether it's a restriction or a obstruction because if it is an obstruction then you can open the obstruction but if the disease is outside the lung which is a restrictive lung disease then the bronchodilators will not help in opening or or improving the immune the symptoms of this patient now these three next slides are going to be very important though i had shown it last time but each one of you should remember it again and again uh we had talked about forced vital capacity and we have talked about forced expiratory volume all right so obviously we can't go on discussing what it means because that's part of what we have already finished but today is going to be an important aspect of the spirogram or the curves or the graphs which are seen on a spirometry report and many times we need to see the pattern of these graphs to really know what is obstruction and what is restriction so just try to focus on this force vital capacity mild moderate severe we have discussed this you should know that there is a copd guideline which is the gold guideline which talks about the fev1 upon fvc ratio this also we had discussed in detail in fact few of you could try to interpret also the spirometry reports which we showed you last time so there is mild moderate severe and very severe all right so there are many uh classifications which we can make into mild moderate severe and very severe depending on the fev1 you can see that the post bronchodilator fev won more than 80 60 to 80 percent 30 to 60 30 to 50 and less than 90 so that is the classification of copd so this is the same one based on which the gold stages it stage one stage two stage three and stage four now these things become important because when the patient is talking to you you is going to talk in terms of severity how severe is the problem is it very severe is it less severe so you need to stage it and of course the other important obstructive disease is asthma so we have got a mild moderate and severe persistent asthma mild persistent moderate persistent and severe persistent where we talk only of the fev1 and see the improvement okay that is the post bronchodilator but here the first the primary fev1 more than 80 percent 60 to 80 percent and less than 60 so those are the mild moderate and severe classification of asthma uh another thing before we go into the pfts is about the reversibility i had mentioned that when we say reversible you need to see the improvement in the fev1 the forced expiratory volume for second if the improvement in the fev1 is more than more than 12 percent and more than 200 ml so 200 ml will be the absolute value and the percentage will be more than 12 when both these things happen only and only then we can say that there is a reversibility in the bronco constriction that it's a reversible obstructive airway disease so that's forms the background for those who feel that this is this is not being knowing to us please you will have to refer to the first part without that it's just not possible for anyone who is joined today to just immediately know about these values but this flowchart is like a summary for the people who would want to know how to easily go ahead with interpretation of a report so you need to obviously look at the fpv one first you see the fbc as we mentioned then you see the whether it is a my restriction moderate restriction or a severe restriction you are going to take a look at the fev1 also and you are also going to take a look at the fev1 upon fbc also both the things you are going to look into because both of them are going to help us know whether it is a copd or whether it's a reversible obstructive airway disease for example let's take one example here uh if in this particular report you can see the fbc so the fpc over here is 87 you can see the fpc is 87 predicted look at the column of percentage predicted fbc is 87 that means it is above 80 percent so it is definitely no restriction then you have to look at the fpv one upon fbc it is underlined here in the third column which is 60 65.5 percent so it is less than 70 that means there is a obstructive airway disease because if ev1 by fpc is less than 70 it means obstruction so it is showing obstructive airway disease now you need to see the fev1 how much is the fpv one here in this the percentage predicted for fpv one you see the percentage predicted so in that it is underlined it is 770 and in the same row you can see the fev1 post bronchodilator post bronchodilator is 76 right so it is only six percent improvement it's only a six percent improvement and we said that the improvement should be more than 12 percent to say that it is a reversible obstructive airway disease so as per this spirometry report there is no restriction because the fpc is 87. you are seeing the fev1 fpc it is 65 so there is an obstruction you saw the fev1 it is 70 and post bronchodilator it is improving to 76 percent that means the improvement is only six percent so by this report you can tell the patient or you can analyze it that this is an obstructive aerial disease but it is not a reversible obstructive airway disease okay this is only on one single report that i have that we are talking about but last time i had also mentioned that you need to have a trend of the spirometer reports you should not rely only on one what is happening after three months or what was happening before three months you need to put together in line and then understand whether this is a reversibility or not reversible or is this only a acute process where he came with reversibility or irreversibility there could be a patient of asthma whose lung function or spirometry you do and it's normal that is called as the stage of remission remission means now there is no spasm so the report is normal okay so please go through the earlier presentation it is very important and forms the background of what we are going to discuss today we before we move on to the spark of spirograms let's try to check this report once for let us let us see what you people feel uh fpc here is 92 i am just trying to help you out fbc here is 92 percent so it is a normal fpc look at the fev1 fpc it's in the blue column it is 86 that means it is about 70 so now what will be the interpretation of this report can anyone try to let me know what is the interpretation of this report would it mean it's a restriction would it mean it's an obstruction or would it mean it's a normal report try to try to see if you can guess or analyze it any one of you so here the fpc is normal and yes the fuel upon accuracy is also normal perfect so this report is a normal spirometry all right this could be a again as i said the spirometry is normal but if you ask the history he may tell you that dr three months ago i had a severe attack on wheezing so it could be that he had asthmatic attack episode that time but now it is completely controlled so it's a it could be asthma and remission so don't rely that asthma means spirometry has to be abnormal no it depends on what phase of asthma you are looking into great now we go ahead with the important and very important aspect of a spirometry report so when you are shown a report you will see a diagram like this which is called as the flow volume loop please go through it very slowly you take time to understand what it exactly tells us this may be more pertinent for those who are doing doing respiratory medicine practice but so there is a x axis and a y axis x axis is the volume is the volume of air which he has inhaled and the y axis is the flow so it's a flow volume loop it's a loop so it's called as a flow volume loop and as you start interpreting spirometries you will actually look at the flow volume loop and you will realize that this is obstructive or restricted just from the loop so first of all look at the area below the x-axis so that's the inspiratory loop okay that's the inspiratory the one below the x-axis and the one above is the sorry the the one below the x-axis is the inspiration and then the exhalation is above the x-axis so so inspiration and expiration so this is the this is the way it is shown as a loop flow volume loop the inspiration goes below the x-axis then the expiration starts if you have ever seen a spirometry being done the person is told first take a deep breath so he takes a deep breath the moment he takes a deep breath there is a graph which comes as the inspiratory loops and then he is told exhale with force the moment he starts exhaling he exhales the first volume of air with force and that's why you can see the peak peak of the expiratory flow that's why it is called as a peak expiratory flow rate so that goes very high in the expiratory arm and then as the volume of air starts coming from the bronchi the bronchioles the segmental bronchioles the terminal bronchioles the alveolar sacs the volume starts decreasing decreasing decreasing all right so there would be a inspiration which is very even he takes a deep breath takes a deep breath so there is an inspiratory curve which has happened then he is told forcefully exhale say maro and he starts exhaling exhaling exhaling exhaling exhaling exhaling the moment he starts exhaling the first volume of air which comes out is a peak expiratory flow the flow is in a peak so the flow is in peak and the volume exit is very high the peak expiratory flow rate and then the volume starts decreasing and decreasing decreasing decreasing decreasing so that will be the flow volume loop all right so please understand this step by step because everything matters on the next few slides how you're going to analyze it so this is again a representation which is seen on a spirometry so you can see the patient is taking a deep breath deep breath deep breath inspiration he is reaching up to his inspiratory reserve volume so he's taking a deep breath deep breath deep breath he's taking his maximal inspiration so there is a inspiratory reserve volume then he starts exhaling with force it reaches the expiratory reserve volume and then he exhales exhales exhales exhales exhales as long as he can so in short we are measuring the inspiratory volume the inspiratory tidal volume the expiratory tidal volume and the expiratory reserve volume so that will be the first vital capacity okay the forced vital capacity now if you have this diagram in front of you and you can see the fpc mentioned on it in a patient who has a restrictive lung disease okay so let's let's put it like this the one we have discussed in the last lecture those people who have a restrictive lung disease we said their lungs are unable to inflate because there is something from outside so the fbc will reduce so the loop over here in the inspiration will be a smaller loop compared to a normal loop and the expiratory loop will also be a smaller loop in terms of the volume in terms of the volume the shape of the curve will be the same but it will be a miniature of the normal okay so the person is taking a breath but he is unable to take a deep breath why is he able to take a deep breath because the disease is outside the outside tell you lies compressing or is pressing or is not allowing the alveoli to inflate examples we have discussed interstitial lung disease plural diseases neuromuscular diseases diaphragmatic diseases obesity all of them will not allow the lung to inflate so the fbc will reduce and in the flow volume loop the graph of a restriction will be a miniature of a normal because the volume is reducing let's let's see further so you can still understand it a little easier so again this is the way it is about the inspiratory and the expiratory you can see the curve that is very important you see the curvature of the inspiration it is a very smooth semi-circle then the peak which goes to the peak expiratory flow rate and then it comes down to the baseline that is the x-axis so you can see the change or the difference in the inspiratory curve and the expiratory curve now we will try to break this down into smaller parts okay smaller parts i hope you are understanding i am trying to explain it as easy as much easily as possible but it's not so simple to really understand a spirometry uh you know so go through it again and again only then you will be able to make out what is the meaning of all this so f i f is the first inspiratory flow in the percentile 20 in the 75th percentile then the fyf is the 50th percentile and f5 25 the 25th percentile now it may not really make a big difference in your interpretation these particular values but what it means is when you take a breath the air is going inside into the smaller airways then the larger airways then the larger airways then the trekkie and while exhaling we are going to exhale the first blast of air will be from the trachea then the bronchi then the bronchioles then valvular sacs then the angular ducts okay now the larger airways are called bronchi the smaller airways are called as bronchioles okay larger airways are called as bronchi and the smaller airways are called as bronchioles you have heard a word very commonly used as bronchitis bronchitis means inflammation of the bronchi but let me tell you there are many more patients who actually have small airway inflammation which is termed as bronchiolitis okay small airway obstruction or bronchiolitis and that's the reason why we need to know whether this patient has got bronchitis or bronchiolitis or both large and small airway obstruction we need to know whether there is either of them okay both of them so for the bronchi bronchioles that is the smaller airways we need to see the fef 25 to 75 percentile okay the fef means the later part of the exhalation you always see the expiratory arm for obstruction please remember for obstruction always look at the expiratory arm okay expiratory arm so one is the peak expiratory flow which is the large air which is going to be the blast of air the peak it reaches then gradually it will be the bronchi the lobar bronchi the main bronchi then the bronchioles and as we come down towards the fef50 fef75 it will be the smaller airways so now you can see the loop of the expiration and as we reach the x-axis during the expiratory graph we are talking of the smaller airway obstruction in the early part of the expiratory arm it will be the larger airway obstruction okay hope you are understanding because it's only going to be the shape of the curves which are going to tell you further about the graphs now the larger graph over here you can see the larger graph here or let's say the flow volume loop that's a better way to use the terminology in the larger flow volume loop is the normal one you can it's mentioned over there you can see the inspiratory curve then the expiratory curve now within that there is another flow volume loop you can see the inspiratory curve is fine it is proper it is semi-circle the expiration starts and there is a initial upstroke and then there is a concavity which is seen in the later part of the flow volume loops can you see that can you notice that see the normal curvature of the flow volume loop and see the curvature of the expiratory arm in the smaller flow volume you can see there is a concaving there is a inward drawing this means that the volume is going still down and lesser and lesser during the expiratory phase and volume goes decreasing in the expiratory phase when there is narrowing of the airways so narrowing of airways there is a narrowing of airways and there is a passive recoil so the recoil is unable to open the airways and it has to come through a narrow air outside as it comes to the narrow area outside through a narrow airway the volume of air takes a longer time to go and the volume is much smaller than what it should be so as the volume is smaller we can see that there is a concaving happening in the expiratory arm in an obstructive airway disease let's i assume you have been able to understand it but as we progress perhaps it may be a little easier now let us compare what i am talking about so we can see a normal flow volume loop we can see a obstructive flow these are all diagrammatic okay once you see the spiral spirometry and spirograms you will be able to do it you will be able to understand it much easier so this is less like a approximation to make you understand the curvature in the expiration so you can see the normal obstruction i think that is very very conspicuous the difference in them especially in the expiratory arm if you see the restrictive one and check the volume okay see the volume volume is much lesser in the restrictive flow volume loop right so the fbc is less we said that the fpc means the total volume which is going in the graph the inspiration and the expiration will be the forced vital capacity we can't measure the residual volume residual volume is still within the lungs so the volume is less in the restrictive lung disease wow so now we have to have multiple different different flow volume looks you see so it is a more interesting one and as you actually start seeing spirometry you can see the loop and say oh you have got obstructive lung disease oh you have got a restrictive lung disease so a spirometry is not only about values of fpc and fev1 it is actually seeing the different loops these are the different loops which are there of course the rarer ones so why volume more in obstructive than in normal let me see no no no so that's what uh in this this is the i think someone is asking dr jayadi why is the volume more than more and more in obstruction then in [Music] then no so this is not a comparison this is not a comparison of the same patient it is just to show that the in in drawing or the concaving is there okay it is not about about the volume will remain the same in a patient in obstruction also the inspiratory volume remains the same it is not going to increase not going to decrease okay the inspiratory volume is going to be the same there are there are certain diseases like emphysema now in emphysema what happens is the lung is already hyperinflated it's already hyperinflated now you tell him to take a deep breath he can't take a deep breath because the lungs are already hyperinflated so in emphysema the tidal volume may actually reduce okay it may actually reduce it won't increase the tidal volume may reduce so so don't have a comparison that this is of the same patient it is just to tell you about the curvature of the graphs so again this is also a diagrammatic representation it won't be seen what is exactly seen we'll see a spirogram or a report then you will be able to understand so normal now you second to see the second flow volume early small air obstruction you can see the drop or the curvature or the concavity is in the distal part of the expiratory loop it's in the distal part that means in the fef 25 to 75 or in the smaller airways so the second patient will have will be what will be the second patient have more likely to have bronchitis or more likely to have bronchiolitis the second flow volume just next to the normal one there is a flow volume so which would be the disease which would be possible in the one with the second flow volume will it be more in favor of a bronchitis or more in favor of bronchiolitis yes so this would be more in favor of a bronchiolitis now see all these things are not just to make terminologies it is also about treatment so if there is treatment of bronchiolitis it may be different from that of bronchitis not completely but there could be some changes which you may have to do to find out whether there is a bronchiolitis okay there could be more air trapping with bronchiolitis because smaller airways may trap the alveolar sacs and the air trapping would be more a patient with bronchitis will have a lot of secretions because there are a lot of mucous glands there is extensive mucous glands mucus secretion in the patient with bronchitis in bronchiolitis in smaller airways very less mucus glands so he may have actually dry cough so if a patient comes to you let's put it in a patient's per perspective a 55 year old man comes to you and says about kasi or i am a getting cough for last four five months i hardly get any sputum i don't expect today or not i get cough i feel that cough should come out but nothing is coming out and when i walk when i climb staircases i feel breathless okay i feel short of breath so we don't know what's happening his x-ray doesn't show anything clinically there are repetitions so you are confused what would could you be why is he getting dry cough he is having breathlessness you do a spirometry and you actually find that there is bronchiolitis small airway disease so in such a patient you need to plan the treatment whether oral steroids will help whether there are certain inhalers which contain extra fine particulate so inhalers contain extra fine particulates and they can actually reach or go into the smaller airways extra fine particulates so those inhalers are there so you may have to plan your pharmacotherapy yes so smokers cough can smokers cough is a entity which is related to smoke causing the cough reflex it could be in the bronchi it could be the smaller airways but yes smaller airways are are possibly going to be affected in smokers much more so that could be smoker's cough but then we need to treat it quitting smoking is going to be the first plan of management but then we need to also give him some bronchodilators or anti-inflammatory now let's go to the third flow volume loop you can see that there is a concaving to a significant extent now if i ask you just compare the second and the third flow volume loop okay the second and the third which one has a severe obstruction the second one or the third one which one has a severe obstruction the second one or the third one so try to see the second loop and the third loop the flow volume loops and check whether there is a obstruction in there is definitely an obstruction in both the loops yes so the third one is having severe obstruction as compared to the second so automatically you did not have to actually look into the fpv one value is it 60 is it 50 is it 40 if you have the same uh spirometries he's come to you with a flow volume loop of january and today he's come to you with the flow of whole flow volume loop which is the third one you compare these two flow volume loops the first one and the present one and you immediately know or something is going wrong this patient's obstruction has increased either he is not taking the inhaler correctly or i need to change the inhaler i need to see what is triggering his airway obstruction so airway obstruction can be triggered by even a simple thing as a gastroesophageal reflux it could be perfumes it could be occupation it could be many other things which you need to be concentrating on so use these investigations to plan the treatment not just to say okay this is obstructive this is restricted you're going to plan the treatment based on this then the fourth loop is the fixed large airway obstruction we can maybe sometime deal with this these are not very common so i'm not going to really focus today on these things variable but you can make out from the loop you see the inspiratory loop okay on the fourth flow volume look look at the inspiratory loop you can see it's almost like a rectangle it's like a rectangle so this means there is a fixed large airway obstruction there is a fixed large airway obstruction so there could be a mass which is actually constrict which could be actually causing a blockage of the trachea it could be a mass which is causing the blockage of the trachea now this can be variable like for example there could be a thyroid there could be thymus which are pressing from outside okay so there could be various reasons why such a graph can happen so variable extra thoracic large area obstruction you can see this graph the inspiratory is like a box it's like a rectangle all right and restrict you now again don't go to the diagrammatic we will take more examples so probably you will have you will be able to find it easier to understand let me ask you a question now let me see if these are all already the examples are coated down so i don't think i can ask you much on this yeah so let us go through this particular flow volume loop now you can see over here the normal loop and you can see the different different volumes so you will have different volumes in the spirometry report also the fef 25 fvf75 f50 force expiratory flow rate force expiratory flow rate 50th percentile force expiratory flow rate 70th percentile so all these things are going to actually help you in planning the treatment and you can see the dotted line in the first flow volume is the normal curve the dotted line in the expiratory arm and you can see how it concavity comes up in the obstruction okay so there is an obstruction which is seen in this particular flow volume loop go through it again all these things are important and one look at it will not will not really emphasize the the plan of treatment so you go through this again especially now you can see the normal flow volume loops just next to that just beside that you can see a restrictive pattern the normal loop is shown in gray and the restrictive pattern is in the red all right so it just shows that the volume is decreased so it's a restrictive lung disease example this could be an interstitial lung disease then if you come down just below the normal flow volume loop you can see a obstructive pattern okay there is a obstructive pattern you can see the expiratory arm is completely narrow it's completely concave compared to the gray so the gray is the one which is normal now you see just next to that there is a fixed upper airway obstruction now what is happening in this fixed upper airway obstruction the inspiratory curve is also like a rectangle and the expiratory curve is also like a rectangle so there is a fixed upper airway obstruction now imagine that over here if there is a laryngeal mass or a laryngeal tumor okay what will happen there will be a strider you press this area even if i smile speaking if i press this my voice changes so if there is a pressure here which is not going to move its not going to open during exhalation also or inspiration also this is going to give a box like pattern in the inspiration as well as the expiration so the moment you see this box like pattern you are going to be worried this could be a tumor this could be a growth this could be something which is compressing the airway the larynx so it's a fixed upper airway obstruction fixed upper airway obstruction whereas if you see a box like pattern in the inspiratory loop only during the inspiratory but during expiration you can see a normal loop it is called as a variable extra thoracic obstruction variable extra thoracic obstruction it is not fixed so it is called as variable okay so there are different box like patterns there is a loop pattern so flow volume loop is actually the best way to look at the reports and then analyze it with the patient history so try to see these things when you see the reports next time okay these are all again i have put the slides again and again and again because it is it you need to just keep on seeing the normal loop and comparing it with what is seen in your patient that's the only way you can check it now let me ask you this question in this particular graph now there are no answers in this so let's see who can you know try to tell me let's see i want an answer for the loop b and loop c do you feel they are obstructive they are restrictive or normal b and c let me see who is able to who is attentive i can put it that way let me see who is attentive is it obstructive or restrictive loop b the flow volume loop in example b and the flow volume loop in example c are they both obstructive or are they both restrictive or are they both normal so dr rohan has said obstructive dr prashanth has said obstructive very good so both are obstructive now you can make out from the loop what is the meaning of obstructive because it is a concavity which is seen now let us see loop d no no one second i think someone just said b is restrictive now b is not restrictive because because the inspiratory volume is the same dr vimal joyce brimla joyce so b is also suggest you of obstruction if you compare the normal as a then in the b you can see a inspiratory loop is normal and you see the expiratory loop and in the expiratory loop there is a dotted line so i am trying to tell those people who feel that the b is restrictive so dr bimla joyce if i am taking the name correctly i'm sorry if i'm spelling it wrong but for dr vindler joyce uh in loop b flow volume to b you can see a dotted line which is the normal and just below that there is a concavity in the expiratory arm so it is suggest you offer obstructive flow volume loops okay so loop flow volume loop b is also obstructive flow volume loop c is also obstructive now let's see d what is cnn d what do you feel it's in d is it obstruction first question second question is it severe obstruction let's go slow and slow on that [Music] so in flow volume loop in the example d so it looks obstructive and it looks severe also so dr rahul uh we are talking of low volume loop number d so in flow volume loop number d try to see whether there is obstruction or restriction [Music] so dr rahul try to see that because you mentioned restriction so i want it to be corrected at this point itself so in the flow volume loop d you can see that there is a dotted line which is showing a normal expiratory loop and the one which is we are talking about is actually much lesser or much concave than the normal so it's a obstructive loop okay it's obstructive flow volume loose yes dr raul i hope you are convinced not just to put on the answer but i hope you are understanding why we are talk or calling it as obstructive so inspiratory and obstruction i will give an example at this point for all those who have answered correctly if we give this patient the flow volume loop d example patient or bronchodilator we give him four puffs of salivitomol okay what is used for bronchodilation salbutamol it's a fast acting bronchodilator we give him a bronchodilator we tell him to wait for 15 minutes we tell him to wait for 15 minutes and again do a spirometry and now check his flow volume loop okay now to check his full volume loop so suppose i tell you that in this patient of low volume loop d the first the pre-bronchodilator was this obstructive and after the bronchodilator the flow volume loop changed to the dotted line what is the inference from that i am repeating my question in the example of d the full volume loop d this patient we said was obstructive airway disease we gave him a short acting inhaler of a bronchodilator we waited for 15 minutes we repeated his flow volume loop and after that when you saw the flow volume loop it had reached the dotted line that concavity was gone and it had reached the dotted line correct so it indicates that there is a reversible obstructive airway disease it's a reversible obstructive airway disease now for all those clinicians it is best not to comment just like an asthma immediately on seeing one spirometry report don't comment that this is asthma comment that it's a reversible obstructive airway disease our spirometry is not telling us about history it is not telling about ige levels it is not telling us about eosinophilia it is not telling us about wheezing what is it telling it is telling is it reversible not reversible so we will stick to that terminology only so reversible obstructive airway disease you take the history you understand that he is having these episodes again and again and again there is a seasonal factor there is a familiar factor then you can say okay with the spirometry and with the history and with your past history i feel you can you are actually having asthma that will be the correct way to go ahead so now we go to the next one that is c sorry sorry e the flow volume loop e so what can we see in the loop key let me ask you so what is loop e is it obstructive is it restrictive is it normal compare it with the dotted line yes perfect so it is restrictive now those who are answering it is restrict you please remember why you have answered it restrict you here answered it respect restrictive because the fbc has reduced the most vital capacity has reduced okay so there is a restrictive because you are saying the inspiration however if someone feels that this could be mixed i still feel it could be fine as a mixed answer because there are mild concavity in the expiratory arm there is a mild concavity i won't say it is completely fine there could be mix but i would still put my first first impression as restriction now we go to the f now what is seen in f let us see the f1 i think f is the is a is a better example of a mixed or a combined defect okay the f is the combined defect you can see the volume is less the fpc is less and we can see that there is a significant concavity in the expiratory arm so the example f over here is a classical example of a mixed defect or a combined effect restrict you with obstruction so this could be a patient of emphysema emphysema as restriction and obstruction okay this could be a patient of that there are certain interstitial lung diseases which also cause obstruction we have discussed those also so you need to check those you need to think about those and analyze it and apply it to your clinical acumen we have already stopped spoken for almost 45 minutes and still we have to finish one important part this is the flow volume loop which i told you and just below that you can see one more of those graphs which is the volume versus time volume versus time now even this so the spirometry report which you see has got all the three things in it one which we discussed just now the flow volume loop the one below it which is the volume time curve the volume time curve and the third is the values so this is what the spirometry report is the first one the second one and the third one and you need to insist on seeing all the three you should be ideally seeing all the three whether it has been done properly or not patient has performed properly or not so the volume time graph or the curve that is very important and we come to this now last 10 minutes we will talk because otherwise everything will be a mixture of everything so let's try to understand this for next 10 minutes then we stop the x axis is the time the y-axis is the volume okay it's the volume the person is exhaling he's exhaling right he's exhaling exhaling exhaling exhaling so the first the volume increases in the first blast of air which is throwing out the volume increases and this is a purely an expiratory arm okay here we are not looking into the inspiration so you checked here the flow volume loop talks about the inspiration and the expiration this particular the volume time talks of the expiration so please try to understand please try to imbibe this thing it's it's again for a clinician to talk of mathematics and physics is like greek but we are discussing physics we are discussing graphs we are discussing x axis y axis which we all left because we wanted to become doctors but you need to come back to that because we are talking of physics of respiration so the time is on the x-axis and the volume is in the y-axis and when he exhales with force the first volume which comes out is the fev1 the first expiratory volume in the first second and then he exhales exhales exhales exhales exhales till he reaches the fbc so it's a curve it's a volume time curve from exhalation to the fpc it's a complete graph complete spirogram so this particular picture or this these lines are called as pyrogram so in a spirometry report you will have a flow volume loop which we discussed in detail you have the spirogram which is this and we have the values which we have discussed in the first talk so the spirogram now you can make out from this a little little bit easy to understand about a normal then it comes down because the volume is dropping you can see in the first fev one is less we said that fev one less than eighty percent everyone less than sixty percent if you and less than forty percent is suggestive of mild moderate severe asthma so you see the volumes in this particular fev1 if you understand this graph then the fev1 is less in the cvr one means in the mild then the moderate and the severe and as these lines go it indicates the volume is much lesser and lesser and lesser but as you as the person exhales all the air comes out but it takes a longer time for it to come out okay so it may take a longer time for it to come out so in a nor in a spirometric report you will be shown a normal curve it is always in comparison with the normal so at least you are saved you don't have to just see one line you need to compare it with the normal now you see in this the dotted line which is the restrictive it is absolutely a miniature of the normal it is just the miniature of the normal it is almost parallel to the normal so it is the same as a normal but the volume is less that's why it's called as restrictive whereas if you see the obstructive lines the mild and moderate and severe the volumes are less but they gradually try to go upwards as the person exhales exhales exhales exhales the air starts coming out so this you will have to understand it in whatever way you can but you will have to remember this when you interpret okay so let's try to see this it's a little simpler way of explaining normal obstructive and restrictive if you have any doubts at this point please put up your question because it will be not possible to come back to discuss these aspects again and again but maybe after you listen to it again next time or maybe during the replay you'll be able to you know give some time because everything has to slowly slowly slowly drench into your mind you cannot suddenly say i understand it so normal obstructive and restrict you see the way the graph or the lines of these things go okay so now let me ask you this question what is the interpretation from this flow volume loop and spirogram i'm using technical words technically correct words you when you see this report you are going to say sir i am going to interpret a flow volume loop and a spirogram that's what you're going to interpret so now tell me what is your interpretation of this patient's spirogram and flow volume loop very good so this this would be straight way going into a obstructive a lung disease we are going to be very sure this is obstructive airway disease all right so it's an obstructive airway disease that is very evident from the spirogram and the flow volume loop and if you actually do a post bronchodilator then you may find that the flow volume loop is changing and it is almost coming toward that concavity is getting lost and it is improving towards the normal which is shown all right now let's see from an actual report what you can make out over here i will give it's written over here though not very clearly seen maybe it's very small but you can see a normal over there the dotted line is the normal the dotted line and there is a blue one you look at the spirogram and there is a blue and a green the blue is the pre-bronchodilator green is the post bronchodilator look at the spirogram okay just check at the spirogram see you can easily i mean if you understood it you know you now you can see the spirogram also and make out what's happening so there is a dotted line which is at the top there is a blue line which is the what the patient has uh you know performed and there is a green which is post bronchodilator look at the spirogram so what do you think is happening here is this is obstructive and yes if it is obstructive then is there a yeah so there is a reversibility now if you really want to know then so if you really want to know how much is the ml of the reversibility you can go on to the y-axis and find out the fev1 if the the amount of volume of change which has happened which may be of help or maybe better and more specific when you see the values but this is obstructive airway this is that is improving host bronchodilators so again just to make go back to your basics the flow volume loop you can see the normal and the inspiratory arm and the expiratory ramp and then the spirogram and how to interpret a spirometry report so there is you can actually have different ways you know you can devise your own ways of flowcharts it doesn't need to be what i am talking about or what is there in the books if you have got a set way of understanding a spirometry report and you are sure nothing is works better than logic okay logic defies everything so what is your logic in interpreting a spirometry stands the test of time if you understood something you can devise your own logic to interpret it but keep your basics correct so you may see the fbc first you may see the fev1 fvc first you may do it the way you wish to do but remember the reasons of decreased fec reasons of decreased fe1 by fpc what is the reversibility criteria whether they are fulfilled or not what is the spirogram yes in spirogram also if more than 200 ml or and and rather more than 200 ml and more than 12 percent of improvement then it means that there's a reversible airway obstruction so all of these are actually going to help you understand interpret and document or what we can say objectively uh come to a conclusion of what is the spirometry uh suggestion of now let's try to do a few uh you know quiz please i can't say a quiz because there's no quiz has a price but i don't think netflix has a price for this but let's try to interpret this whoever wishes to do that you can do that try to do this so let's see what you can interpret this time i'm not going to help you so what does this this report tell us superb so quite a few of you answered it is obstructive that is correct and they have also answered that it is a reversibility is there because the percentage is 28 percent and the absolute value is almost 480 ml so there is a good uh response i feel everyone has been able to uh sort of understand from this report also i think we should stop because there are many many different different reports different ways i think if if even if you don't look at the values forget the values in this slide just look at the flow volume loop and what do you think this is obstructive or restricted just look at the flow volume perfect so from the flow volume you actually need did not have to look into the values you can see the flow volume loop and say this is obstructive then you can go and see okay this is mild or moderate but even looking at the flow volume you can make it is definitely moderate to see where it is not mine so this would be somewhere into a mild a moderate to severe obstructive airway disease now if you see such a report you will tell the patient i want to get a post bronchodilator report done and then i want to see and if there is no improvement that means this is possibly a case of severe or moderate copd so you will have to keep on evaluating different spirometry reports spirograms low volume loops it's it's a constant learning process which you will have to go through and only and only then you will be able to make out uh the different uh you know sort of uh reports uh analyze this so i think we will stop at that because you know talking too many things will confuse everyone just keep it at that stick to the basics keep on looking at reports and google will help you in having those quiz and those who have won the quiz today can have lunch at the places they like with their own money so so so i i am so thank you very much dr rucha for getting me along again i like to speak to my friends thank you so much yes definitely it's pleasure to have you every time and i'm sure everyone enjoys this session i can see amazing comments thank you sir wonderful session excellent explanation uh so you mentioned about quiz we definitely can have a quiz on all the sessions that you have covered we'll definitely plan it and can sure that would be good yes so if anyone has any question please put up in the comment section i'll just give you two minutes because uh pft i totally get sir's point that it's very difficult to understand here and so it has tried amazingly so this is my complete revision of prp so if you have any questions just put it in the comment section or you can raise hand and you can interact with sir directly uh so let me just check if there are any but i can see very happy to present with the seminar excellent session many regards excellent class and explanation the best lecture i have attended so far regarding on this topic thank you dr zaria i can't see any questions it's all praising comments uh that's nice that's amazing so uh even if you i don't have any questions right now just like sir mentioned you can go back to replay watch it again at your convenience and if there are any questions you can pass on to us so just one minute there's a question about in which conditions we get both so usually the commonest one is copd specifically emphysema it can present with obstruction and restriction even bronchiectasis is one common disease which will have both obstruction and restriction and there are certain interstitial lung disease which can have obstructive component as well even for that matter hypersensitivity pneumonitis is one disease which can present with obstruction and restriction so these would be the common neurons see dr jayadip is asking so once you do spirometry and it is an obstructive report so do we need to report the spirometer how often do we need to do it again means after we report this if there is obstruction how how need to be repeated repeat it okay so so so so there is no guideline or recommendation for how long how many times you need to repeat it but a three months therapy would be an adequate time to repeat and see what change has happened in the spirometry okay okay uh so can we find any changes on spirometry and respiratory failure so what are the typical changes characteristic changes so respiratory failure first of all you know for whoever is asking we need to know whether it's a type 1 respiratory failure type 2 respiratory failure and spirometry is not an indication in respiratory failure per se because as we know a typical spirometry is to take a deep breath very forceful breath exhale with force exhale with also in a patient with respiratory full failure in fact it is not advisable to tell them to do this they are already hypoxic they are having tachypnea so one is that they will not be able to perform it and second it's not going to change the diagnosis and treatment since we are already diagnosed with respiratory failure right so i hope this uh answers your question dr nasma uh so dr mithsal is asking does all of these patients should be recommended pfp with the lco absolutely so all these patients need to be investigated as doctor is saying absolutely correct a pre and a post bronchodilator even a complete lung function test which will include a dsu it definitely helps in understanding and to realizing whether they have what a component of obstructive airway disease and along with that we should recommend them to do a sleep study irrespective of whether they are snoring or not snoring so i fully go with that suggestion pre post with tlc and sleep study okay thank you sir with this we have covered all the questions as well so just one last i will take the spirometry exercise yes so respiratory diseases the backbone of treatment of 90 percent of respiratory diseases is physiotherapy okay 90 of them so physiotherapy makes a big difference including incentive spirometry deep breathing exercises postural drainage so i would recommend that all those who are treating uh asthma copd ild fibrosis bronchitis please discuss this with your physiotherapist take them into confidence and refer them to the physiotherapist they are the best people to explain about incentive spirometry and the different breathing exercises so holistic approach again here absolutely for the treatment thank you sir thanks a lot uh for your time and it is wonderful to happy thank you bye good day for all right good day bye everyone

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