N2 washout is affected by N2 excretion and other factors

The Lung Clearance Index (LCI) was first described in 1952 by Margaret Becklake, and is defined as the number of lung volume turnovers required to reduce the concentration of a tracer gas by a factor of 40. LCI is calculated as the cumulative exhaled volume (CEV) during the washout divided by the functional residual capacity (FRC).

Clinically LCI has been used most often in individuals with cystic fibrosis and this is because the LCI has been repeatably shown to be sensitive to changes in airway status that are not reflected in the FEV1. LCI has shown similar results in patients with primary ciliary dyskinesia. As expected LCI has also been tested on patients with COPD, bronchiectasis and asthma although these patients tend to show a better correlation between FEV1 and LCI.

LCI has been performed using a wide variety of tracer gases including helium, methane, argon, nitrogen and sulfur hexaflouride (SF6). The commercial systems that are currently available use either N2 or SF6. N2 washout LCI has recently received a great deal of criticism and some of these criticisms seem to apply to N2 washout lung volumes as well.

Most specifically, a number of studies have noted that the N2 washout FRC is routinely higher than the SF6 FRC and plethysmographic FRC. In addition, the N2 washout LCI tends to be significantly higher than the SF6 LCI and this difference increases as LCI increases.

As examples in a study of patients with COPD the N2 washout FRC averaged 14% higher than the plethysmographic FRC. In other studies of normal subjects the N2 washout FRC was on average 0.20 to 0.21 L higher than plethysmographic FRC. Finally, a study that performed N2 and SF6 washouts simultaneously on CF patients and healthy controls showed the N2 washout LCI to be on average 7.93% higher than SF6 in the healthy controls and 29.13% higher than SF6 in the CF patients. In the same study N2 washout FRC was 12.66% higher than SF6 FRC in the healthy controls and 30.09% higher than SF6 FRC in CF patients.

So why is there such a discrepancy?

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FEV1 and VC should be measured separately

The FEV1 and VC both provide quite different information about a patient’s lungs. Unfortunately, spirometry as it is currently practiced is optimized towards generating an accurate FEV1 more than an accurate VC. This is partly due to limitations in the maneuver itself and partly due to the lack of accurate end-of-test criteria for an adequate VC. In one sense this is okay since more than one person that I’ve known and respected has said that “it’s all about the FEV1”.

Having said that, an accurate FEV1/VC ratio is essential for detecting and quantifying airway obstruction and an SVC maneuver is more likely to obtain a more accurate VC. This matters because the current ATS/ERS spirometry guidelines recommend that the FEV1/VC be reported, where the VC is the largest value obtained from any test and reference equations indicate that the SVC is routinely larger than the FVC:

So, shouldn’t we be routinely performing both FVC and SVC maneuvers when we do spirometry on our patients? And why aren’t we?

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I’M BACK, SORT-OF

The chemo did a real number on me. I was included in a study of a new drug and it literally almost killed me. Twice. For this reason I have left the study and have been put on a gentler and more normal regime of chemo. I have lost a lot of stamina (and strength and weight) but have recovered somewhat. I have returned to catch up on comments as best I can and apologize for not responding for so long.

If possible I will post something new but it will probably be a while before I feel up to doing so.

Thanks to everybody for their kind and supportive thoughts.