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Functional capacity and residual functional capacity and their utility in measuring work capacity.

OBJECTIVE: The pain physician is often asked to establish the medical impairment of the chronic pain patient (CPP) and from that determination ascertain the work capacity of the CPP. Functional capacity (FC) testing has recently been introduced as a more objective and accurate way of facilitating the determination of work capacity. However, there are conceptual problems with the measurement of FC. These will be reviewed and the relationship of FC to residual functional capacity (RFC) will be determined. Finally, a method for measuring RFC in a job-specific manner will be suggested. DATA SOURCES: The literature in reference to the measurement of medical impairment, FC, and RFC was reviewed. STUDY SELECTION: Studies appropriate to the objective of this review were selected for inclusion. CONCLUSIONS: The FC and RFC are poorly defined. Lack of definition has interfered with design of appropriate test batteries specific to work capacity. To circumvent this problem a job-specific RFC measurement method is suggested. This method is based on the Dictionary of Occupational Titles.

Animals↗

Optimizing liquid ventilation as a lung protection strategy for neonatal cardiopulmonary bypass: full functional residual capacity dosing is more effective than half functional residual capacity dosing.

OBJECTIVE: To evaluate and compare the protective effects of two different perflubron doses on hemodynamics and lung function in a neonatal animal model of cardiopulmonary bypass-induced lung injury. DESIGN: Prospective, randomized, controlled study. SETTING: Animal laboratory of the Department of Surgery, Duke University Medical Center. SUBJECTS: Twenty-one neonatal swine. INTERVENTIONS: One-wk-old swine (2.2-3.2 kg) were randomized to receive cardiopulmonary bypass with full functional residual capacity perflubron (n = 7), cardiopulmonary bypass with half functional residual capacity perflubron (n = 7), or cardiopulmonary bypass alone (n = 7). This last group served as control animals, receiving cardiopulmonary bypass with conventional ventilation. Liquid lung ventilation animals received perflubron via the endotracheal tube at either full functional residual capacity (16-20 mL/kg) or half functional residual capacity (10 mL/kg) before the initiation of cardiopulmonary bypass. Each animal was placed on nonpulsatile cardiopulmonary bypass and cooled to a nasopharyngeal temperature of 18 degrees C (64.4 degrees F). Low-flow cardiopulmonary bypass (35 mL/kg/min) was instituted for 90 mins. The blood flow rate was then returned to 100 mL/kg/min. The animals were warmed to 36 degrees C (96.8 degrees F) and separated from cardiopulmonary bypass. Data were obtained at 30, 60, and 90 mins after separation from cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Cardiopulmonary bypass without liquid lung ventilation resulted in a significant decrease in cardiac output and oxygen delivery and a significant increase in pulmonary vascular resistance in the post-bypass period. Full functional residual capacity liquid lung ventilation administered before bypass resulted in no change in cardiac output and oxygen delivery after bypass. Full functional residual capacity liquid lung ventilation resulted in lower pulmonary vascular resistance after bypass compared with both control and half functional residual capacity liquid lung ventilation animals. CONCLUSIONS: These data suggest that liquid lung ventilation dosing at full functional residual capacity before bypass is more effective than half functional residual capacity in minimizing the lung injury associated with neonatal cardiopulmonary bypass. Full functional residual capacity dosing may optimize alveolar distention and lung volume, as well as improve oxygen delivery compared with half functional residual capacity dosing.

Analysis of Variance↗

Measurement of lung diffusing capacity and functional residual capacity in lambs during the first postnatal month.

The diffusing capacity of the lung for carbon monoxide (DLCO) is an important index of lung function but is not easily measured in spontaneously breathing animals with small lung volumes. Our aim was to devise a simple rebreathing method that would allow us to make serial measurements of DLCO in spontaneously breathing lambs during their first month after birth. By adding He to the rebreathing gas mixture, we were also able to measure functional residual capacity (FRC), enabling us to normalize DLCO with respect to FRC. We have compared FRC measured by the rebreathing technique with that measured by a closed-circuit helium dilution method (FRCcc). Using the rebreathing method we found highly significant positive correlations between DLCO and body weight (r = 0.70, P < 0.001) and between FRC and body weight (r = 0.79, P < 0.001). There was no significant change in DLCO/FRC over the first postnatal month; the mean value was 8.1 +/- 0.6 mL/min/mmHg/mL. Rebreathing FRC was highly correlated with FRCcc (r = 0.88, P < 0.001), but was lower than FRCcc by about 18%. In normal lambs DLCO and FRC, but not DLCO/FRC, increased during the first month after birth, suggesting that the increase in DLCO parallels lung growth. We conclude that the modified rebreathing method is suitable for measuring DLCO in small uncooperative spontaneously breathing animals.

Analysis of Variance↗

Maximal expiratory flows at functional residual capacity: a test of lung function for young children.

Maximal expiratory flows at functional residual capacity were measured noninvasively from partial expiratory flow-volume curves in 65 awake, healthy children, 4 to 6 years of age. The variabilities within and between subjects were nearly identical to those reported for flows low in the vital capacity obtained from older subjects. This test of maximal expiratory flow at functional residual capacity has the advantage that the subject does not have to inspire to total lung capacity, exhale to residual volume, or make a maximal effort, and it is therefore applicable to the testing of young children who cannot perform a vital capacity maneuver. Measurement of this flow rate in 20 patients of the same age with lung disorders of varying severity revealed abnormal flow rates in more than 50 per cent of patients. Functional residual capacity was measured by the closed-circuit helium-equilibration method. When flow rates in liters per sec were compensated for lung size, girls had significantly larger flow rates than did boys. This suggests that the lungs of young children may grow differently according to genetic determinants related to sex.

Adolescent↗

Functional residual capacity related to hepatic disease.

Functional residual capacity was measured in 20 children (aged 3.1-11.2 years) with liver disease. Children with severe liver disease, regardless of diagnosis, had reduced functional residual capacities (less than 80% of expected). Children with alpha-1 antitrypsin deficiency had higher functional residual capacities than those with other hepatic diagnoses. Three children had a functional residual capacity greater than 120% of expected, all had alpha-1 antitrypsin deficiency.

Child↗

Increase of functional residual capacity in hemorrhagic shock.

Functional residual capacity (FRC) was measured by body plethysmography in anesthetized dogs subjected to hemorrhagic shock. This was elicited by bleeding the animals to a mean arterial blood pressure of 4 kPa. Reinfusion was done at 30% spontaneous uptake of the maximal bleeding volume. During the initial rapid bleed-out and early hypovolemia, the FRC increased proportionally to the bleeding volume by an average factor of 0.19. Subsequently FRC increased further to about 50% above the control level, and it remained elevated even after reinfusion. Minute ventilation reached a peak value of about 2.5 times of that of the control state, and then declined to almost control values in late hypovolemia when FRC was still very high. The mechanism of the significant increase in FRC is not clear, but it is suggested that the balance of its effects is unfavorable to the maintenance of adequate ventilation in late shock.

Animals↗

The effects of expiratory positive airway pressure on functional residual capacity in normal subjects.

Functional residual capacity (FRC) was determined by constant volume, whole body plethysmography in seven normal subjects under resting conditions and following the addition of increasing levels of expiratory positive airway pressure (EPAP). There was a significant increase in FRC in six of the seven subjects studied. Grouped data showed a progressive increase in FRC with increasing EPAP (p less than 0.01). The highest level of EPAP (15 cm H2O) was associated with a 20% increase in FRC. We have been able to confirm that EPAP provides a simple and effective method of increasing FRC which could be applied to the treatment of conditions characterized by temporary and reversible reduction in lung volume.

Adult↗

Measurement of pulmonary diffusing capacity for carbon monoxide and functional residual capacity during rebreathing in conscious thoroughbreds.

A rebreathing method for measurement of pulmonary diffusing capacity for carbon monoxide (DLCO) and functional residual capacity (FRC) was evaluated in conscious horses. Horses were manually ventilated through an endotracheal tube, using a custom-made syringe filled with a gas mixture containing 18-carbon monoxide (18CO) and helium (He). The 18CO and He concentrations were continuously monitored by use of a mass spectrometer connected to the rebreathing circuit. Values for DLCO and FRC were calculated from changes in the concentration of these 2 gases. In 11 Thoroughbreds, mean (+/- SD) DLCO was 330.3 +/- 56.9 ml.min-1 x mm of Hg-1, and FRC was 20.21 +/- 3.35 L. Body weight normalization yielded mean (+/- SD) values of 0.652 +/- 0.114 ml.min-1 x mm of Hg-1 x kg-1 for DLCO, and 39.9 +/- 6.4 ml.kg-1 for FRC.

Animals↗

The bias flow nitrogen washout technique for measuring the functional residual capacity in infants. ERS/ATS Task Force on Standards for Infant Respiratory Function Testing.

The functional residual capacity (FRC) is the most commonly measured static lung volume in infants. It is important for interpreting volume-dependent pulmonary mechanics, e.g. airway resistance, and defining normal lung growth. The bias flow nitrogen washout technique is widely used for measuring FRC because the dead space and circuit resistance are low, making it suitable for small or sick infants. Moreover, data acquisition and calculation are easily programmed for a personal computer. The aim of this paper is to provide recommendations pertaining to equipment requirements, study procedures and reporting of data for functional residual capacity measurements. While measuring the functional residual capacity is regarded as physiologically and clinically important, the accuracy of the measurement is undoubtedly equally important. Hence, the paper also emphasizes factors influencing the accuracy of functional residual capacity measurements independent of equipment requirements. These recommendations represent the "State of the Art" in 2000.

Clinical Protocols↗

Lung function in infants and young children: functional residual capacity, tidal volume, and respiratory rats.

Functional residual capacity was measured by the closed-circuit, helium-equilibration method in 121 normal children 3 months to 6 years of age. Prediction equations for functional residual capacity for normal children of this age range are presented for the first time. This study demonstrates that some aspects of lung functiok can be studied relatively conveniently in young children.

Body Height↗

Perioperative changes in functional residual capacity in morbidly obese patients.

Functional residual capacity (FRC) was measured before and after induction of anaesthesia for jejunoileal bypass surgery in 30 morbidly obese patients. The onset of anaesthesia was associated with a 51% reduction in FRC from 2.2 litre to 1.0 litre. Eighteen of the patients were investigated more extensively; in these subjects FRC was reduced below the control values of residual volume (RV) with the onset of anaesthesia, but recovered towards baseline after laparotomy incision. Reduction in FRC is related to baseline vital capacity (VC) and FRC and is much greater than that reported for patients of normal weight.

Adult↗

[Normal values of functional residual capacity (author's transl)].

The functional residual capacity (FRC) was measured in 24 healthy subjects, 1-by the helium dilution method using a closed system and an open system during washout, and 2-using a constant pressure plethysmograph. Results obtained with the three methods were not significantly different. Furthermore, FRC was determined by helium dilution in 177 healthy men and in 100 healthy women, aged between 18 and 77 years. In both sexes, FRC was dependent on age, height (H) and weight, being greater in the taller, older subjects. For a given height and age, FRC decreased with increasing weight. Correlation coefficients between logarithm of (FRC/H3) and age and/or weight were highly significant. From these allometric relationships, it was possible to calculate FRC reference values, and then, reference values for other functional tests such as steady state TLCO and lung compliance.

Adolescent↗

Changes in functional residual capacity of the lung after operation.

Functional residual capacity (FRC) of the lung was measured by the closed-circuit helium equilibration method before and for five days after upper abdominal operations in 28 patients (25 had cholecystectomies). Measurements in many were made with the patient both sitting in bed and sitting in a chair. Vital capacity (VC), residual volume (RV), and forced expiratory volume in one second (FEV1), as well as FRC, all decreased after operation, with the maximum decrease on days 1 and 2 and a gradual return toward preoperative values by day 5. Patients with 40% or less decrease in FRC after operation did not develop pulmonary complications. Change in position from bed to chair increased FRC 14.2% preoperatively and 17% postoperatively. The use of intermittent positive pressure breathing had no measurable effect on FRC. Similar changes in FEV1, VC, and RV also occurred, with maximum decreases on day 1.

Adolescent↗

Three-dimensional reconstruction of the in vivo human diaphragm shape at different lung volumes.

The ability of the diaphragm to generate pressures at different lung volumes (VLs) in humans may be determined by the following factors: 1) its in vivo three-dimensional shape, radius of curvature, and tension according to Laplace law; 2) the relative degree to which it is apposed to the rib cage (i.e., zone of apposition) and lungs (i.e., diaphragm dome); and 3) its length-force properties. To gain more insight into these factors we have reconstructed from nuclear magnetic images the three-dimensional shape of the diaphragm of four normal subjects under supine relaxed conditions at four different VLs: residual volume, functional residual capacity, functional residual capacity plus one-half of the inspiratory capacity, and total lung capacity. Under our experimental conditions the shape of the diaphragm changes substantially in the anteroposterior plane but not in the coronal one. Multivariate regression analysis indicates that the zone of apposition is dependent on both diaphragm shortening and lower rib cage widening with lung inflation, although much more on the first of these two factors. Because of the changes in anteroposterior shape and expansion of the insertional origin at the costal margin with lung inflation, the data therefore suggest that the diaphragm may be more accurately modeled by a "widening piston" (Petroll's model) than a simple "piston in a cylinder" model. A significant portion of the muscular surface is lung apposed, suggesting that diaphragmatic force has radial vectors in the dome and vectors along the body axis in the zone of apposition. The muscular surface area of the diaphragm decreased linearly by approximately 41% with VL from residual volume to total lung capacity. Diaphragmatic fibers may shorten under physiological conditions more than any other skeletal muscle. The large changes in fiber length combined with limited shape changes with lung inflation suggest that the length-twitch force properties of the diaphragm may be the most important factor for the pressure-generating function of this respiratory muscle in response to bilateral phrenic shocks at different VLs.

Diaphragm↗

Effects of partial liquid ventilation with perfluorodecalin in the juvenile rabbit lung after saline injury.

OBJECTIVE: To evaluate the feasibility of using the perfluorochemical, perfluorodecalin, for partial liquid ventilation (PLV) with respect to gas exchange and lung mechanics in normal and saline-injured lungs of juvenile rabbits. DESIGN: Experimental, prospective, randomized, controlled study. SETTING: Physiology laboratory at a university medical school. SUBJECTS: Seventeen juvenile rabbits assigned to three groups. INTERVENTIONS: The conventional mechanical ventilation (CMV)-injury group (n = 5) was treated with CMV after establishing a lung injury; the PLV-injury group (n = 6) was treated with PLV after lung injury; and the PLV-healthy group (n = 6) was supported with PLV without lung injury. Lung injury was created by repeated saline lung lavages. PLV-treated animals received a single dose of intratracheal perfluorodecalin at a volume equal to the measured preinjury gas functional residual capacity (functional residual capacity = 18.6+/-1.5 [SEM] mL/kg). MEASUREMENTS AND MAIN RESULTS: Sequential measurements of total respiratory compliance and arterial blood chemistries were performed in all groups. Oxygenation index (OI) and ventilation efficiency index were calculated. After lung injury, there was a significant (p < .05) decrease in PaO2, total respiratory compliance, and ventilation efficiency index and an increase in OI and PaCO2. In the PLV-injury group, PLV significantly (p < .05) improved PaO2 (+60%) and OI (-33%) over time. Compliance was significantly (p < .05) higher (90%) than in the CMV-injury group over time. CONCLUSIONS: These results demonstrate that PLV with perfluorodecalin improved oxygenation and increased respiratory compliance in the saline-injured rabbit lung. In addition, similar to the effects of several other perfluorochemical liquids on normal lungs, pulmonary administration of perfluorodecalin was associated with a small impairment in gas exchange and a significant decrease in lung compliance in the juvenile rabbit model.

Animals↗

Three-dimensional reconstruction of human diaphragm with the use of spiral computed tomography.

We developed a technique of diaphragm imaging by using spiral computed tomography, and we studied four normal subjects who had been previously investigated with magnetic resonance imaging (A. P. Gauthier, S. Verbanck, M. Estenne, C. Segebarth, P. T. Macklem, and M. Paiva. J. Appl. Physiol. 76: 495-506, 1994). One acquisition of 15- to 25-s duration was performed at residual volume, functional residual capacity, functional residual capacity plus one-half inspiratory capacity, and total lung capacity with the subject holding his breath and relaxing. From these acquisitions, 20 coronal and 30 sagittal images were reconstructed at each lung volume; on each image, diaphragm contour in the zone of apposition and in the dome was digitized with the software Osiris, and the digitized silhouettes were used for three-dimensional reconstruction with Matlab. Values of length and surface area for the diaphragm, the dome, and the zone of apposition were very similar to those obtained with magnetic resonance imaging. We conclude that satisfactory three-dimensional reconstruction of the in vivo diaphragm may be obtained with spiral computed tomography, allowing accurate measurements of muscle length, surface area, and shape.

Adult↗