Significance and Pathophysiology

Gerard Achilles M. Obnial

 The rebreathing method (DLCOrb) allows for normal breathing without arterial puncture
DLCOrb is less sensitive to V/Q abnormalities and uneven ventilation distribution The rebreathing method is sensitive to the accumulation of COHb in capillary blood and resultant back pressure

 Capillary PCO is assumed to be zero

Rebreathing method can be used during exercise if breathing is carefully controlled Acetylene can be added to the diffusion mixture to measure CO

Adding nitric oxide allows DLNO to be measured in rebreathing

 Measuring DLCO using intrabreath method (DLCOib) does not require holding breath at TLC
Patient must inspire enough volume of test gas so that subsequent exhalation will clear the instrument and anatomic VD Single-breath exhalation must be slow and even, and a flow restrictor may be necessary in some systems

 Single-breath slow exhalation produces values similar to breath-hold method in health patients when flow is 0.5L/sec
Uneven distribution of ventilation may produce elevated intrabreath DLCO values Measurement of membrane (Dm) and RBC components (Vc) of diffusion resistance in healthy patients accounts for half of total resistance to gas exchange in alveocapillary membranes

 Measurement of partial pressure of O2 in the pulmonary capillaries using membranediffusing capacity determination is restricted
Uptake of nitric oxide is limited by pulmonary capillary membranes DLNO can be measured to assess membrane resistance

Physiologic factors influencing observed DLCO

1. Hemoglobin and hematocrit directly proportional to DLCO ; CO uptake varies approximately 7% per gram of Hb

2. COHb - COHb levels reduce DLCO ; Diffusion gradient for CO in alveolocapillary membranes is equal to the alveolar pressure of CO

3. Alveolar PCO2 PCO2 is directly proportional to DLCO and inversely proportional to PO2
4. Pulmonary capillary blood volume Increased blood volume in the lungs (VC) causes increased DLCO. Patients must be seated and resting for several minutes before DLCO

5. Body position Supine position increases DLCO

6. Altitude above sea level altitudes significantly greater than sea level, DLCO increases unless corrections are made
7. Asthma and obesity associated with increased DLCO in some studies; exact physiology is unclear