Interpretation of the Flow-Volume Loop

We will only discuss the interpretation of the most important test (Forced Vital Capacity).

The flow-volume shape can take on a few distinguishable shapes that correspond to a certain type of pathology:

Normal Spirometry

A normal flow-volume loop:

A normal Flow-Volume loop begins on the X-axis (Volume axis): at the start of the test both flow and volume are equal to zero. After the starting point the curve rapidly mounts to a peak: Peak (Expiratory) Flow.

After the PEF the curve descends (=the flow decreases) as more air is expired. A normal, non-pathological F/V loop will descend in a straight or a convex line from top (PEF) to bottom (FVC).

The forced inspiration that follows the forced expiration has roughly the same morphology, but the PIF (Peak Inspiratory Flow) is not as distinct as PEF.


A normal volume-time loop:

Another way of representing the spirometry test is through the volume-time graph. The start is at coordinates 0-0 (at time 0, flow is 0). Since most air is expired at the beginning, when the patient empties his large airways, the graph rapidly rises. About 80% of total volume is expired in the fierst second. As the lungs are emptied the rise in expired volume gets lower and lower to end in a horizontal level.

Spirometry values are compared with predicted values. If the spirometry values are lower than 80% of predicted values, the values are considered to be too low.

To assess the Tiffeneau index, we do not look at the percentage compared to predicted values, but at the percentage of FEV1 to FVC of the test session (the best FEV1 and FVC of all reproducible tests are used). The value is considered to be too low if it is less than 70%.

Since publication of the new GLI predicted values (in 2012) the Lower Limits of Normality are taken into account and no longer the fixed 80% rule. If a value is lower than the LLN it is considered to be abnormal. This also applies to the Tiffeneau index.

Obstructive Lung Disease

In patients with obstructive lung disease, the small airways are partially obstructed by a pathological condition. The most common forms are asthma and COPD.

A patient with obstructive lung disease typically has a concave F/V loop.

Flow-volume in obstructive lung disease:
is concave, FEF25-75 too low, FVC normal

The air in the large airways usually can be expired without problems, so PEF may be normal.

When all the air is expired from the large airways, air from the smaller airways will be expired. With obstructive lung disease, these airways are partially blocked, so the air will come out slower (you can simulate this by blowing out through a straw!).

This will result in a lower flow and a (more or less) sharp fall in the flow-volume .
FEV1 and FEF25-75 will be too low.

Typically the patient will have a normal FVC at the early stages of his condition.

The FET (Forced Expiratory Time) will be higher due to the lower flow but equal volume.

Volume-time curve in obstructive lung disease: FEV1 low, FET higher

A Tiffeneau index (FEV1/FVC x 100) of less than 70% is very suggestive for obstructive lung disease.
A bronchodilator test will be necessary for a more accurate diagnosis.

Since the Tiffeneau index is known to decline with age, nowadays the Lower Limits of Normality are taken into account. In this case obstructive lung disease is diagnosed if Tiffeneau is lower than LLN values for the patient's age.

Restrictive Lung Disease

Restrictive lung disease means that the total lung volume is too low. Although an accurate diagnoses of total lung volume is not possible with spirometry (residual lung volume cannot be measured with a spirometer) spirometry results can be very suggestive for a restrictive lung disease.

Since the airways are normal, the flow volume loop will have a normal shape: the curve will descend in a straight line from the PEF to the X-axis.

Flow-volume in restrictive lung disease:
shape normal, FVC low

Total lung volume is low, which results in a low FVC. PEF can be normal or low.

FEV1 is equally lowered than FVC, so the Tiffeneau index will be normal or even raised.

Volume-time curve in restrictive lung disease:
FEV1 too low, FET normal

Mixed Lung Disease

Often patients will show signs of both obstructive and restrictive lung disease. The flow-volume loop will have characteristics of both syndromes.

Flow-volume loop in mixed lung disease:
FVC, FEV1 and FEF25-75 too low

Large Airway Obstruction

A typical shape of the flow-volume loop is seen in cases of obstruction of the large airways.

Three different shapes of flow-volume loops can be distinguished.

Variable Extrathoracic Obstruction

Typically the expiratory part of the F/V-loop is normal: the obstruction is pushed outwards by the force of the expiration.

During inspiration the obstruction is sucked into the trachea with partial obstruction and flattening of the inspiratory part of the flow-volume loop.

This is seen in cases of vocal cord paralysis, extrathoracic goiter and laryngeal tumors.

extrathoracic obstruction

Variable Intrathoracic Obstruction

This is the opposite situation of the extrathoracic obstruction. A tumor located near the intrathoracic part of the trachea is sucked outwards during inspiration with a normal morphology of the inspiratory part of F/V-loop.

During expiration the tumor is pushed into the trachea with partial obstruction and flattening of the expiratory part of the F/V loop.

intrathoracic obstruction

Fixed Large Airway Obstruction

This can be both intrathoracic as extrathoracic.

The flow-volume loop is typically flattened during inspiration and expiration.

Examples are tracheal stenosis caused by intubation and a circular tracheal tumor.

extrathoracic obstruction
Typical flattening of flow-volume loop in fixed airway obstruction