2017 ERS DLNO standards

The European Respiratory Society has just published the first standards for DLNO testing. This is a signal that DLNO is moving from a research setting into routine clinical testing. Although it is unlikely that most PFT labs will immediately jump into DLNO testing, the standard is still interesting because of an extensive discussion of DLNO, DLCO, DMCO and Vc measurements and physiology. The DLNO standards (and their supplementary material) are open-access and can be downloaded from the European Respiratory Journal.

DLNO is performed in the same manner as a single-breath DLCO and it is specifically recommended that DLCO and DLNO tests be performed simultaneously. There are however, specific test system requirements based both on the properties of NO and on the two types of NO analyzers:

  • Nitric Oxide reacts with oxygen to form NO2 and at the levels used for DLNO testing (40-60 ppm) does so at a rate of approximately 1.2 ppm per minute. DLNO test gas is therefore usually stored as 400-1200 ppm NO in N2 and mixed into the DLCO test gas mixture (0.3% CO, 21% O2) ≤2 min before the DLCO/DLNO test. This would seem to require that the DLCO/DLNO test gas mixture to be held in a reservoir of some kind and to preclude the use of a demand valve but this was not specifically discussed. Because of uncertainties that occur when mixing the DLCO/DLNO gas mixture and in how long the mixture may be held in the reservoir the inspired NO concentration must also be measured immediately before the DLCO/DLNO test is performed.
  • The type of NO gas analyzer will determine how the expiratory gas concentrations are measured. Chemiluminescent analyzers usually have a response time on the order of ≤70 msec, and for these reasons can be used to perform a real-time analysis of exhaled air. Chemiluminescent analyzers are expensive however, and can add significantly to the cost of a test system. Electrochemical cells are significantly less expensive but have a response time on the order of 10 seconds and are therefore suitable only to test systems that mechanically collect an alveolar sample.

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Some DLCO errors the 2017 standards will probably fix

Last week I ran across a couple errors in some DLCO tests that I don’t remember seeing before, or at least not as distinctly as they appeared this time. If I hadn’t been looking carefully I could have missed them but both sets of errors will be a lot more evident when the 2017 ERS/ATS DLCO standards are implemented.

The first error has to do with gas analyzer offsets. What alerted me was a set of irreproducible DLCO results.

Test 1: Test 2: Test 3: Test 4:
DLCO (ml/min/mmHg): 24.53 17.21 12.91 6.74
Inspired Volume: 1.99 2.06 2.32 2.26
VA (L): 3.83 3.52 3.63 2.60
Exhaled CH4: 43.27 49.19 54.80 74.14
Exhaled CO: 16.09 23.15 31.39 49.46

When I first looked at the graphs for each test, there wasn’t anything particularly evident until I pulled up the graph for the fourth DLCO test:

This graph showed that the baseline CH4 and CO readings were significantly elevated, but this hadn’t been evident in the previous tests.

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What’s the frequency, plethysmograph?

Once again we’ve had some staff turnover. Rightly or wrongly, the pattern we follow in staffing the lab is to hire people with a science degree and then train them ourselves. Our hires are usually interested in a career in medicine but often haven’t decided what specifically interests them. We look for individuals with people skills on top of their education and ask for a minimum of a year’s commitment with the requirement that they get their CPFT certification by the end of the year. Sometimes our staff only stays a year, sometimes a couple years, and most of the time when they leave they go back to college for a more advanced degree and become nurses or physician assistants and occasionally even physicians (a couple of our pulmonary fellows were former PFT lab alumni).

We do this mostly because it’s very hard to find anybody with prior experience in pulmonary function testing. I’d like to say this is a recent occurrence but realistically it’s been this way for decades. One of the reasons for this is that there are no college level courses on pulmonary function testing. Although the training programs for respiratory therapists often include some course work on PFTs this is almost always a one semester lecture course with no hands-on training (when it is included at all).

Another reason is that trained individuals often do not stay in this field. This is partly because there isn’t much of a career path since the most you can usually aspire to is being a lab manager but even then I know of many small PFT labs where the manager is somebody outside the field such as a nurse or administrator with no experience in pulmonary function testing so often that isn’t even an option. Another reason though, is that the PFT Lab pay scale, although adequate, is often noticeably less than other allied health professions such as radiology techs, ultrasound techs and sleep lab techs.

Anyway, the downside of this hiring pattern is that it seems like we’re always hiring and training new staff (however untrue that may actually be). We do have a fairly good training program however, so new staff usually come up to speed and become reasonably productive in a short period of time. Even so, it takes at least a year before a new technician is reasonably proficient not just in performing the tests, but in understanding the common testing problems and errors. This is at least one reason why I spend much of my time reviewing raw test data and sending annoying emails to the lab staff.

It also means that we frequently revisit basic testing issues.

Recently, a report with a full panel of tests (spirometry, lung volumes, DLCO) came across my desk. The patient had had a full panel a half a year ago and when I compared the results between the two sets of tests there had been no significant change in FVC, FEV1 and DLCO but the TLC was over a liter higher than it had been last time.

Jan, 2017 June, 2016
Observed: %Predicted: Observed: %Predicted:
FVC: 2.04 85% 2.38 97%
FEV1: 0.58 32% 0.62 34%
FEV1/FVC: 28 38% 26 36%
TLC: 7.27 152% 6.10 126%
FRC: 6.16 222% 4.83 174%
DLCO: 8.12 51% 8.91 55%

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