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The Open Circuit Nitrogen Washout Technique for Thorax: First Published As 10.1136/Thx.54.9.790 on 1 September 1999

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The Open Circuit Nitrogen Washout Technique for Thorax: First Published As 10.1136/Thx.54.9.790 on 1 September 1999 790 Thorax 1999;54:790–795 The open circuit nitrogen washout technique for Thorax: first published as 10.1136/thx.54.9.790 on 1 September 1999. Downloaded from measuring the lung volume in infants: methodological aspects Mohy G Morris Abstract sophisticated equipment and a well trained Background—Lung volume measurement operator and cannot generally be performed at by nitrogen washout is widely used in the bedside or be used in sick infants. Gas dilu- infants, though a lack of accuracy and tion employs either helium or nitrogen as the changes of calibration over time have been tracer gas. The open circuit nitrogen washout reported. The potential sources of error technique is widely used because the dead were explored in order to increase the space and circuit resistance are lower than in accuracy and reliability of the technique. the helium closed circuit, making it suitable for Methods—A commercial system for nitro- small or sick infants. Moreover, data acquisi- gen washout and a 0.5 litre calibrating tion and calculation are easily programmed for syringe as a lung model were used to per- a personal computer.1–5 form over 2000 in vitro washouts, includ- While the measurement of lung volume has ing simulated rapid breathing, shallow been regarded as physiologically and clinically breathing, periodic breathing, sighs, and important,12the accuracy of the measurement brief apnoeas. A constant 10 l/min bias is undoubtedly equally important. A commer- flow of oxygen and extended equipment cial system has been used for the past 10 years warming times were employed. A collaps- or so in infant pulmonary function laboratories ible breathing bag was incorporated into to measure the functional residual capacity 4 the washout circuit. Following a single two (FRC) by nitrogen washout. Studies using this point calibration, known air volumes from system have occasionally explored the accuracy 42 ml to 492 ml were measured by nitro- of the nitrogen washout technique and possible 5 gen washout over a 14 hour period. The sources of errors. A change of calibration over flow waveform in the nitrogen mixing time was noted in a study on healthy infants chamber during a washout in vitro, with and, despite eVorts by the investigator to recheck calibration immediately prior to sub- and without the breathing bag in the http://thorax.bmj.com/ ject testing, a correction factor had to be used circuit, was also studied. 5 Results—The mean coeYcient of varia- on several test results. Indeed, a recent study tion of all volumes was 0.66%. The mean comparing lung volume measurements by diVerence between measured and known whole body plethysmography and nitrogen volumes was 0.30 ml (95% confidence washout reported a lack of accuracy and interval (CI) –0.18 to 0.79). This difference reliability of the two techniques in infants with was not statistically significant (p = 0.22). airway obstruction and concluded that no “gold standard” technique was available for use The mean percentage error was –0.1% 6 (range –0.47% to 0.46%). Nitrogen calibra- in this setting. on September 28, 2021 by guest. Protected copyright. tion remained stable for 14 hours. Without The primary aim of this investigation was the breathing bag flow transients were therefore to enhance the accuracy of measure- frequent in the mixing chamber during in ments and achieve a reliable calibration of the vitro washout. nitrogen washout technique by a systematic exploration of potential sources of errors in Conclusions—This technique increases the accuracy in vitro and the precision in vivo vitro using a calibrating syringe as a lung model, and ultimately to develop a method that of volume measurement by nitrogen wash- renders volume measurements by nitrogen out. Sources of potential errors including washout reliable and reproducible in vitro and baseline drifting and inadequate equip- in vivo. We also wanted to establish the linear- ment warming times were identified. The Department of ity of the system over a wide range of volumes breathing bag acted as a buVer reservoir, Pediatrics, Pulmonary so that a single two point calibration could be Medicine Section, preventing large swings in flows within the employed to measure the functional residual University of Arkansas nitrogen mixing chamber during wash- capacity (FRC) and, using a newly developed for Medical Sciences, outs, and should be an integral component Arkansas Children’s method, the residual lung volume (RV) in of the nitrogen washout circuit. Hospital, Little Rock, infants.7 Arkansas 72202-3591, (Thorax 1999;54:790–795) USA M G Morris Keywords: lung function tests; gas dilution; nitrogen Methods washout; infants A commercial system known as the Pediatric Correspondence to: Pulmonary Unit (PPU) 2600 (SensorMedics, Dr M G Morris. Anaheim, California, USA) was used. A Measurements of lung volumes in infants have 0.5 litre calibrating syringe (Hans Rudolph Received 6 May 1999 Accepted for publication been performed using whole body plethysmo- Inc, Kansas City, Missouri, USA) was em- 10 June 1999 graphy and gas dilution. The former requires ployed as a lung model. Open circuit nitrogen washout technique for measuring lung volume in infants 791 NITROGEN WASHOUT TECHNIQUE 15 mm OD × 10.5 mm ID. The oxygen flow of Thorax: first published as 10.1136/thx.54.9.790 on 1 September 1999. Downloaded from The open circuit nitrogen washout method for a high precision flowmeter (Timemeter Instru- assessment of FRC(N2) as described by ment Corporation, Lancaster, Pennsylvania, Gerhardt et al3 involves measuring the volume USA) was accurately set by adjusting the mid- of nitrogen expired after end tidal expiratory dle of the float to the 10 l/min mark. This flow switching of the inspired gas from room air to was used for all tests. The oxygen tubing (King 100% oxygen. RV(N2) was also estimated after Systems Corporation, Noblesville, Indiana, end forced expiratory switching.7 At a constant USA) was connected to the 3.18 mm ID end bias flow that exceeds the infant’s inspiratory of an adapter (Hospitak Inc, Farmingdale, peak flow during tidal breathing, the integrated New York, USA), the other end of which expired nitrogen is multiplied by the constant (22 mm ID) fitted onto the 22 mm OD of a flow of oxygen to obtain the volume of expired “T” connection (“T” piece; Intersurgical Inc, nitrogen. A two point calibration is performed Cazenovia, New York, USA). A 0.5 litre with known air volumes. With the amount of collapsible breathing bag (Vital Signs Inc, nitrogen washed out measured and the initial Totowa, New Jersey, USA) was attached to the fractional alveolar nitrogen concentration centre port (22 mm ID) of the “T” connection × known (FAi(N2) room air = 0.79), the lung via an adapter (22 mm OD/19 mm ID volume at which the washout was initiated can 22 mm OD/17 mm ID; Baxter Healthcare be calculated578as follows: Corporation, Deerfield, Illinois, USA), and lung volume (FRC or RV) = volume N the distal (third) end (22 mm ID) of the “T” 2 connection was fitted onto an aerosol “T” washed out/FAi(N2) The PPU has an operator controlled adapter (22 mm OD; Hudson Respiratory pneumatic slide valve that switches the infant Care Inc, Temecula, California, USA). The to breathing 100% oxygen. The expired gas centre port (15 mm ID) of the aerosol “T” then enters a mixing chamber that is con- adapter was inserted onto the small port nected via a precision needle valve and a (15 mm OD) of the three way slide valve situ- vacuum pump to a nitrogen analyser and the ated at right angles to the mouth port. The nitrogen concentration is integrated electroni- opposite end (22 mm OD) of the aerosol “T” adapter was inserted into a distensible cou- cally by the PPU signal processing system. The × nitrogen washout curve is displayed in real pling connector (29 mm OD 17 mm ID; time on the computer monitor. When a 0% Marquest Medical, Aurora, Colorado, USA) nitrogen concentration is displayed on the to obtain a snug fit. A Concha Hose Adapter monitor, the slide valve is activated and the (Respiratory Care Inc, Arlington Heights, Illi- infant is switched back to breathing room air nois, USA) joined the other end of the and FRC(N )orRV(N) are automatically coupling connector and the proximal end of a 2 2 × calculated by the system. 2.0 m long hose (Tygon, 9.53 mm ID 15.88 mm OD; Baxter Healthcare Corpora- A systematic exploration of possible sources http://thorax.bmj.com/ of error when using the nitrogen washout tech- tion) with a snug fit. The distal end of the hose nique was undertaken. Potential sources of was inserted into the 11 mm OD end of an error encountered, suggested, or reported adapter (Marquest Medical, Aurora, Colo- included (1) changes in background oxygen,5 rado, USA) whose other end (22 mm ID) fit- (2) the infant’s peak flow exceeding the ted snugly into the inlet port of the nitrogen background flow, (3) a change in calibration mixing chamber. A 1.8 m long (22 mm ID) over time,5 (4) switching at end tidal expiration corrugated tube (Baxter Healthcare Corpora- when FRC57was measured or leaks in the cir- tion) was attached to the outlet port of this cuit, including the face mask, and in infants chamber and was loosely coiled in an open box on September 28, 2021 by guest. Protected copyright. with airway obstruction, (5) the unanswered on the side of the PPU. This tube prevented question of the final nitrogen concentration, ambient air from diVusing back into the nitro- and (6) length of the washout time and the gen mixing chamber.
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