2. Main questions about each case : 1. Is there any abnormal pattern in spirometry 2. What ‘s your estimate of the degree of limitation? 3. What are differential diagnosis

3. Step 1. Look at the Flow-Volume loop Step 2. Look at the FEV1 (Nl ≥ 80% predicted). Step 3. Look at FVC (Nl ≥ 80%). Step 4. Look at FEV1/FVC ratio (Nl≥ 75%). Step 5. Look at FEF25-75% (wide normal range)

4. 1 - good start of test : sharp take off 2- Meet end-of-test criteria 3- free from artifacts: Cough or glottis closure during the first second of exhalation Variable effort, submaximal effort Leak Obstructed mouthpiece Have a satisfactory exhalation 6 s of exhalation Acceptability Criteria

5. After 3 acceptable spirograms been obtained  Are the two largest FVC within 150ml of each other?  Are the two largest FEV1 within 150ml of each other? If both of these criteria are met, the test session may be concluded. If both of these criteria are not met, continue testing until Both of the criteria are met with analysis of additional acceptable spirograms; OR a total of eight tests have been performed Reproducibility Criteria

6. goldcopd.com

10.  Obstructive Disorders  FVC nl or↓  FEV1 ↓  FEF25-75% ↓  FEV1/FVC ↓  TLC nl or ↑  Restrictive Disorders  FVC ↓  FEV1 ↓  FEF 25-75% nl to ↓  FEV1/FVC nl to ↑  TLC ↓

13.  Decreased DLCO (<80% predicted)  Obstructive lung disease  Parenchymal disease  Pulmonary vascular disease  Anemia  Increased DLCO (>120-140% predicted)  Asthma (or normal)  Pulmonary hemorrhage  Polycythemia  Left to right shunt

14. case 1 65 year-old man No pulmonary complaints PFT as part of a routine health screening test Lifelong non-smoker Prior history of asbestose exposure

15. His flow volume loops is as follows: :

16. 54 year – old man With dyspnea &cough Non-smoker,with no occupational exposures. His flow volume loop is as follows: Case 2

18. Flow volume loop: PEFR Scooped out appearance Decreased FEV1,FVC & FEV1/FVC moderate airflow obstruction BD response Dx: obstructive disease Case 2 interpretation

19. 60 year-old man With progressive dyspnea on exertion 40 pack-year smoker Retired following as a building contractor His flow volume loop is as follows: Case 3

20. The units for DLCO are ml/min/mmHg

21. Case 3 interpretation Redused FEV1,FVC&FEV1/FVC very severe obstruction Significant BD response Increased RV air trapping

22. 25 year-old man With dyspnea and wheezing Non smoker History of motor vehicle accident, hospitalization and tracheostomy 2 years ago Case 4 His flow volume loops is as follows:

24. Case 4 interpretation Flow volume loop: Flattened inspiratory &expiratory limb Decreased FEV1, FEV1/FVC moderate obstruction Dx: Fixed UAWO

25. 41 year-old woman With dyspnea on mild exertion History of 10 pack-year smoking and IV drug abusment (heroin and Ritalin) Her flow volume loop is as follows: Case 5

27. Flow volume loop : PEFR Scooped out pattern Decreased FEV1,FVC,FEV1/FVC very severe obstruction Increased RV air trapping No BD response DDx: Alpha 1 AT Dficiency, Ritalin lung Case 5 interpretation

28. 30 year-old woman Dyspnea on exertion from 2 month ago Non-smoker,No PMH She has a cat and parrot at home. Case 6 Her flow volume loop is as follows:

30. Decreased FEV1,FVC + NL FEV1/FVC Rstrictive pattern Decreased TLC severe restriction Decreased DLCO Case 6 interpretation

31. Pulmonary Function Tests Pre- and Post-Treatment CT Scan Images Dx :Hypersensitivity puemonitis

32. 73 year-old man Progressive dyspnea on exertion,dry cough over the past one year. No fever,hemoptysis and sputum production Life-long non-smoker Case 7

34. Flow volume loop : tall, narrow, short expiratory phase Decreased FEV1,FVC + NL FEV1/FVC +decreased TLC restrictive pattern Severe Restriction Decresed DLCO Case 7 interpretation

35. PA and Lateral Chest X-Ray Chest CT Images Dx :IPF

36. Her spirometry is repeated with her in the upright and supine positions: 64 year-old woman With dysnea and orthopnea Non-smoker Case 8

37. Decreased FEV1,FVC,FEV1/FVC + Decreased TLC Mixed restrictive,obstructive pattern DDx : CHF Diaphragmatic weakness(reduced more than 20% in FEV1&FVC in supine position) Case 8 interpretation

38. 35 year-old man With dyspnea,fever,chills and night sweat from 2 month ago Non smoker,no occupational or habit exposure His flow volume loop is as follows: Case 9

40. Flow volume loop : 2 component in expiratory limb faster emptying of one lung Decreased FEV1,FVC, FEV1/FVC + Mixed Res. obs. Pattern Decreased TLC Severe Obs. & modrate Res. case 9 inetrpretation :

41. Chest X—Ray Chest CT Dx : large mass and collapse

42. 53 year old woman With increasing dyspnea on exertion. No cough,fevers,hemoptysis,weight loss or sweat. Occasional chest pain with syncope or palpitation. Case 10

43. DLCO is measured in ml/min/mmHg

44. FEV1,FVC,FEV1/FVC,TLC NL No limitation Isolated decreased DLCO Dx : CTEPHN Case 10 inetrpretation

45. 36 year –old woman Worsrening dyspnea on exertion and exercise limitation. Life-long non-smoker No PMH. DLCO is measured in ml/min/mmHg Case 11

46. Decreased FEV1,FVC,NL FEV1/FVC Res. Pattern Decreased TLC Modreate RVD DLCO ~ NL Probably extrinsic process Further evaluation: 17% drop in supine FVC MIP = -35 MEP= 50 Dx = muscle weakness( Limb Girdle Dystropy) Case 11 interpretation

47. 44 year-old woman with cirrhosis Increasing dysnea. worse in upright position and walking.improves in supine position. 8% reduction in O2Sat from supine to sitting position DLCO is measured in ml/min/mmHg Case 12

48. Decreased FEV1/FVC + NL FEVI &FVC Mild OVD No BD response Decreased DLCO probably due to pulmonary vascular disease Platypnea +Orthodeoxia vascular intrapulmonary shunt hepatopulmonary syndrom Case 12 interpration:

50. 1 - good start of test : sharp take off 2- Meet end-of-test criteria 3- free from artifacts: Cough or glottis closure during the first second of exhalation Variable effort, submaximal effort Leak Obstructed mouthpiece Have a satisfactory exhalation 6 s of exhalation Acceptability Criteria

51. After 3 acceptable spirograms been obtained  Are the two largest FVC within 150ml of each other?  Are the two largest FEV1 within 150ml of each other? If both of these criteria are met, the test session may be concluded. If both of these criteria are not met, continue testing until Both of the criteria are met with analysis of additional acceptable spirograms; OR a total of eight tests have been performed Reproducibility Criteria

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56.  Obstructive Disorders  FVC nl or↓  FEV1 ↓  FEF25-75% ↓  FEV1/FVC ↓  TLC nl or ↑  Restrictive Disorders  FVC ↓  FEV1 ↓  FEF 25-75% nl to ↓  FEV1/FVC nl to ↑  TLC ↓

59.  Decreased DLCO (<80% predicted)  Obstructive lung disease  Parenchymal disease  Pulmonary vascular disease  Anemia  Increased DLCO (>120-140% predicted)  Asthma (or normal)  Pulmonary hemorrhage  Polycythemia  Left to right shunt