When lung volumes are measured in a plethysmograph the actual measurement is called the Thoracic Gas Volume (TGV). This is the volume of air in the lung at the time the shutter closes and the subject performs a panting maneuver. Ideally, the TGV measurement should be made at end-exhalation and should be approximately equal to the Functional Residual Capacity (FRC). For any number of reasons in both manual and automated systems this doesn’t happen and the point at which the TGV is measured is either above or below the FRC.
Testing software usually corrects for the difference in TGV and FRC by determining the end-exhalation baseline that is present during the tidal breathing at the beginning of the test. Using this value the software can determine where the TGV was measured relative to the tidal breathing FRC and then either subtracts or adds a correction factor to derive the actual FRC volume.
One problem with this is that leaks in either the subject or the mouthpiece and valve manifold can occur during the panting maneuver and the end-exhalation baseline can shift and this will affect the calculation of RV and TLC. I’ve discussed this previously and as a reminder, RV is calculated from:
RV = [average FRC] – [average ERV]
where the FRC is determined from the corrected TGV and ERV is determined from SVC maneuvers. TLC is then calculated from:
TLC = RV + [largest SVC]
When the post-shutter FRC baseline shifts upwards (higher lung volumes relative to the pre-shutter FRC):
ERV is underestimated, which in turn causes both RV and TLC to be overestimated. When the post-shutter FRC baseline shifts downwards (lower lung volumes relative to the pre-shutter FRC):
ERV is overestimated, which in turn causes both RV and TLC to be underestimated.
I’ve been aware of this problem for quite a while and use this as a guideline when selecting the FRCs and SVCs from specific plethysmograph tests. All of these assumptions are based on the fact that FRC is derived from the pre-shutter end-exhalation tidal breathing. Well, you know what they say about assuming…
I’ve discussed the issue of inserting a predicted FVC into the predicted lung volumes several times now. At the risk of beating this issue to death I’d like to put to rest the notion that an FVC and an SVC are the same thing.
A Forced Vital Capacity (FVC) maneuver is designed to measure the maximum expiratory flow rates, in particular the expired volume in 1 second (FEV1). It has long been recognized that the effort involved in the FVC maneuver can cause early airway closure, even in individuals with normal lungs, and that for this reason the vital capacity can be underestimated due to gas trapping. This effect is usually magnified with increasing age and in individuals with obstructive lung disease.
A Slow Vital Capacity (SVC) maneuver is designed to measure the lung volume subdivisions Inspiratory Capacity (IC) and Expiratory Reserve Volume (ERV), and to maximize the measured volume of the vital capacity. Due to the more relaxed nature of the SVC maneuver there is significantly less airway closure and for this reason the SVC volume is usually larger than the FVC, again even in individuals with normal lungs.
Comparing individual reference equations can be difficult but in general the reference equations for SVC and FVC agree with this. Taking the available SVC and FVC reference equations (unfortunately limited to Caucasian because there are almost no SVC equations for other ethnicities) it is apparent that the average predicted SVC is larger than the average predicted FVC, and that the magnitude of this difference increases with age:
I’ve had a number of reports across my desk in the last couple of weeks with both elevated and reduced FRC’s that were associated with a more-or-less normal TLC. I reviewed the raw data from all of these tests (I review the raw data from all lung volume tests) and in only a few instances did I make any corrections to the report. This made me think however, about what, if anything, is an abnormal FRC trying to tell us?
The answers to that question range from “a whole bunch” to “not much” to “darned if I know”. When you measure lung volumes TLC is really the only clinically important result. RV can be useful at times but although the other lung volume subdivisions may play a role in the measurement process they have only a limited diagnostic value. All lung volume measurements start with FRC, however, and if you don’t know you have an accurate FRC how do you know that TLC is accurate?
FRC is a balance point of opposing forces in the lung and thorax. Lung tissue wants to collapse, the rib cage wants to spring open and the diaphragm wants to do whatever muscle tone, gravity and the abdomen allows it to do. All of these forces are to one extent or another dynamic and can change over time. These changes can occur both slowly and rapidly, and are the primary reason why isolated changes in FRC don’t tend to have a lot of clinical significance. For all lung volume measurements however, one primary assumption is that FRC does not change during the test and this isn’t necessarily true.