2011B14 Describe the changes in respiratory function tests that occur with long term increases in small airways resistance.

 

List:

·       Intro: small airway resistance

·       Test results

 

Intro: small airway resistance

Small airways

·  <2mm diameter

·  ≥8th generation

·  <20% total resistance in health due to large total surface area

·  Silent zone: large increase in resistance before detectable

Air flow physiology

·  Flow rate = (P1 – P2) / airway resistance

o Inspiration: PMouth – PAlv

o Expiration: PAlv - PMouth

·  Laminar flow in small airways (small radius, low Reynolds number)

o Resistance = (8 x length x viscosity) / (π x radius4)
(radius power of 4, most important)

Small airway obstruction

·  e.g. asthma, COPD

·  Obstruction in expiration (>inspiration) due to loss of radial traction

o ↓Radius -> ↑airway resistance

§ Variable resistance -> variable alveolar time constants

o Earlier and worse dynamic airways collapse (DAC)

§ ↑Resistance -> ↑Pressure drop -> distal migration of equal pressure point (Pintrapleural = Pairway)

·  Occurs in forced expiration, +/- in tidal expiration if severe disease

o -> ↑RV, ↑FRC, closing capacity, ↓flow rate

Clinical implications

·  Require higher peak airway pressure

·  Require longer expiratory time

·  Risk of gas trapping, breath stacking, volutrauma and barotrauma

Test summary

·  Most sensitive in early disease: ↑CV

·  Most specific to small airways: ↓FEF25-75%

·  Most quantitative of obstruction: ↓FEV1 (80-100% mild, 50-80% mod, <50% sev), ↓PEFR

 

Test results: small airway obstruction

Bedside PEFR

·  ↓ (e.g. 4L/s c.f. 8L/s)

Spirometry

·  ↓FER

·  ↓FEV1

·  ↔↓FVC (less affected)

Static lung volume testing

·  ↑TLC, ↑FRC, ↑RV

·  Helium dilution: underestimates FRC, TLC due to gas trapping (+/- bullae)

·  Whole body plethysmography: accurate

Forced flow-volume curve

·  ↔↓PIFR (affected if severe)

·  ↓PEFR, scooped-out expiratory curve, ↓FEF25-75

·  ↓FVC (less affected)

·  (↑TLC, ↑RV – unable to measure here)

Tidal volume-pressure curve

·  ↑Pressure work

·  ± Active tidal expiration: if
Expiratory work > elastic inspiratory work
i.e. area ABCG’A > area ABCDEA

Single breath nitrogen washout

·  ↑Time constant variation -> ↑slope phase 3

o Poorly ventilated alveoli empty late

·  ↑DAC -> ↑Closing volume (10% in health)

Arterial blood gas

·  If chronic hypoventilation:

o ↑PaCO2 (PACO2 ∝ VCO2/VA)

o ↔↓pH (0.03 per mmHg ↑PaCO2)

o Renal compensation: ↑HCO3- = 24 + 0.4(PaCO2 – 40)

·  If closing capacity > FRC:

o Shunt -> ↓PaO2

Exercise testing

·  ↓Max voluntary minute ventilation -> ↓DO2 and ↑respiratory work -> ↓ peak aerobic power