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The Physiological Basis and Clinical Significance of Lung Volume Measurements Mohamed Faisal Lutfi

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The Physiological Basis and Clinical Significance of Lung Volume Measurements Mohamed Faisal Lutfi Lutfi Multidisciplinary Respiratory Medicine (2017) 12:3 DOI 10.1186/s40248-017-0084-5 REVIEW Open Access The physiological basis and clinical significance of lung volume measurements Mohamed Faisal Lutfi Abstract From a physiological standpoint, the lung volumes are either dynamic or static. Both subclasses are measured at different degrees of inspiration or expiration; however, dynamic lung volumes are characteristically dependent on the rate of air flow. The static lung volumes/capacities are further subdivided into four standard volumes (tidal, inspiratory reserve, expiratory reserve, and residual volumes) and four standard capacities (inspiratory, functional residual, vital and total lung capacities). The dynamic lung volumes are mostly derived from vital capacity. While dynamic lung volumes are essential for diagnosis and follow up of obstructive lung diseases, static lung volumes are equally important for evaluation of obstructive as well as restrictive ventilatory defects. This review intends to update the reader with the physiological basis, clinical significance and interpretative approaches of the standard static lung volumes and capacities. Keywords: Lung volumes, Lung capacities, Obstructive, Restrictive, Spirometry Background pulmonary ventilation, which will be discussed in the Four standard lung volumes, namely, tidal (TV), inspiratory following paragraphs. reserve (IRV), expiratory reserve (ERV), and residual vol- umes (RV) are described in the literature. Alternatively, the standard lung capacities are inspiratory (IC), functional Mechanics of breathing residual (FRC), vital (VC) and total lung capacities (TLC). Towards the end of tidal expiration, the lungs tend to Figure 1 gives a schematic summary of the standard lung recoil inward while the chest wall tends to recoil out- volumes and capacities [1–3]. RV constitutes part of FRC as wards. These two opposing forces lead to a negative well as TLC and, therefore, these capacities are impossible pressure within the potential space between the parietal to measure through simple spirometers. The procedures and visceral pleurae. The negative intrapleural pressure used for measurement of RV, FRC and TLC are based on (PPl) is one of the important factors that keep the radiological, plethysmographic or dilutional techniques (he- patency of small airways, which lack cartilaginous sup- lium dilution and nitrogen washout methods) [4]. However, port. The rhythmic contraction of inspiratory muscles body plethysmography and dilutional techniques may causes cyclic changes in the dimensions of the thoracic under-and overestimate lung volumes and capacities, re- cage and consequently comparable cyclic fluctuation of spectively [5]. For the details of the procedures, advantages, PPl. − − disadvantages and recommendations for best practice of During tidal inspiration, PPl drops from 5to 8 these techniques, the reader can refer to the reports revised cmH2O enforcing the intra-alveolar pressure (Palv)to and published by the joint committee of ATS/ERS [6]. drop one cmH2O below atmospheric pressure (Patm), The way how static lung volumes and capacities Fig. 2a. As a result, air flows into the alveoli. The drop change in different physiological/pathological conditions of PPl also decreases the airways resistance by dilating depends on the understanding of the mechanics of the small airways and thus enhancing the air flow fur- breathing and the physiological determinants of ther. The sequence of events reverses during tidal expir- ation. When inspiratory muscles relax, dimensions of the thoracic cage decrease, PPl increases from −8 back to Correspondence: [email protected] − Department of Physiology, Faculty of Medicine and Health Sciences, 5 cmH2OandPalv increases one cmH2O above Patm. Al-Neelain University, Khartoum, Sudan As a result, air flows outside the alveoli following the © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lutfi Multidisciplinary Respiratory Medicine (2017) 12:3 Page 2 of 12 Fig. 1 Standard lung volumes and capacities from a spirometer trace. The solid black and gray arrows indicate lung volumes and capacities respectively pressure gradient, Fig. 2b. Tidal expiration is therefore a is delivered to the alveoli compared with tidal inspiration. passive process, which needs no further muscle contrac- Alternatively, expiration below the tidal level is an active tion. During tidal breathing, whether inspiratory or ex- process that requires contraction of expiratory muscles. piratory, intra-airways (Paw) pressure is always more During forceful expiration, the thoracic cage is com- than PPl. This explains why small airways are always pressed to the maximum. Both PPl and Palv rise above opened, even at the end of tidal expiration. Patm; however, Palv remains more than PPl due to the effect If inspiration above the tidal limit is required, accessory of elastic recoil pressure (Pel) of the alveolar wall. As dem- muscles of inspiration must be activated. Thoracic cage onstrated in Fig. 3c, Paw decreases from the area next to expands more leading to higher drop in PPl and Palv com- the alveoli upwards. This gradual drop in Paw is secondary pared with tidal inspiration, which explains why more air to simultaneous increase in the airways resistance towards Fig. 2 Intrapleural and alveolar pressures towards the end of inspiration (a), expiration (b), and forceful expiration (c). The dotted line indicates the change in thoracic dimensions during a, b and c compared with the previous phase of the respiratory cycle Lutfi Multidisciplinary Respiratory Medicine (2017) 12:3 Page 3 of 12 Fig. 3 Static PVC of the lungs and chest wall. The lung and chest wall curve was plotted by the addition of the individual lung and chest wall curves the trachea. Taking into consideration the relatively con- Expiration after development of airflow limiting segments stant PPl around the lung, each small airway can be subdi- is effort independent. What remains in the lungs when vided into three segments (Fig. 2c): small airways start to close is called the closing capacity (CC) [12, 13]. Alternatively, RV remains in the lung when An inflated segment, where PPl is lower than Paw. all small airways are closed. The volume of air expired An equal pressure point, where PPl is equal to Paw. between CC and RV is called the closing volume (CV). An airflow limiting segment, where PPl is higher It is evident from the above description that pulmon- than Paw. ary ventilation depends on the airways resistance offered to the airflow and expansibility (compliance) of the lungs Development of airflow limiting segments occurs in and the thoracic cage. These two major determinants of small airways that lack cartilaginous support and ex- pulmonary ventilation are crucial for understanding the plains why the lungs cannot be empty completely. What pattern of change in static lung volume in different types limits airflow upon forceful expiration was previously of lung diseases. explained by development of choke points i.e. the points where local flow velocity equalizes the local speed of 1. Airways resistance pressure wave propagation (wave speed theory) [7, 8]. This is akin to a waterfall in which height and flow up- The tracheobronchial tree undergoes successive di- stream the river are unlikely to affect the speed of the chotomizations, where the airways become narrower but free falling water; nevertheless, if waterfall is broader, an more distensible as we proceed downward. It is, there- extra water will be displaced. It is important to note that fore, difficult to apply simple laws of physics that govern upon forced expiration, the increase in Palv is accompan- fluid flow across single, non-branched, non-distensible ied by gas compression within the lung. This will result tube system to evaluate respiratory airways resistance. in reduction of both lung volume and Pel. The decrease For example, the lowest airways resistance resides on in Pel in turn attenuates the driving as well as the dis- smallest bronchioles but not large airways. Because tending pressures at the choke points. This explains why bronchioles are arranged in parallel, their resistances de- the actual volume of forcefully expired air is always less pend on the total cross sectional area of all bronchioles than that measured with body plethysmograph. Based rather than the radius of a single bronchiole. on the preceding narrative, it is easy to interpret why Airways resistance is inversely proportional to the lung FEV1 measured with spirometer (FEV1-Sp) is typically volume. PPl decreases significantly upon inspiration, less than that measured with body plethysmograph which enhances distension of airways especially small (FEV1-Pl) by an amount equal to thoracic gas compres- bronchioles. At higher lung volumes, attachments from sion volume (TGCV) [9–11]. the alveolar walls pull small airways apart and hence Lutfi Multidisciplinary Respiratory Medicine (2017) 12:3 Page 4 of 12 enhance
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