DLCO- Paediatric

Perspective
Dr. N. Punith Patak
Department of Paediatrics
 DLCO

• In adults DLCO measurement is important to quantify and monitor functional

impairment due to interstitial lung disease, COPD and emphysema

• These are rare diagnoses in children

 DLCO

Diffusion measurements have several pitfalls in children

• Inaccurate in case of severe airway obstruction due to inadequate time for

equilibration of the gases in the airways.
• At reduced lung volume, diffusion per unit lung volume increases and this may
lead to erroneous interpretation of data in children with restrictive lung disease
• use of appropriate reference values, obtained at the relevant lung volumes, is
mandatory
• Falsely high diffusing capacity may be found due to the presence of blood in the
airways and alveoli, or in the case of relative hyperperfusion
Procedure & Limitations
Single breath method

• Limited to adults
• Cooperative children older than 6–8 years who can perform the maneuver
(difficulties in holding their breath for 10 s at TLC)
• VC exceeding 1.5 liters

American Thoracic Society: Single-breath carbon monoxide diffusing capacity (transfer factor). Recommendations for a standard technique –
1995 update. Am J Respir Crit Care Med 1995;152:2185–2198
 Procedure & Limitations
Multiple-Breath Methods
• An alternative method is the rebreathing technique, for
which patients are asked to hyperventilate a gas
mixture containing CO and He.
• However, such a procedure may still be too difficult to
perform for small children.
• Preschool children can be studied using an alternative
rebreathing method at normal, spontaneous
ventilation, where the patient is connected for several
minutes to a closed system filled with a gas mixture
containing 0.3% CO and 5% He, while breathing
quietly
• For small children, the dimensions of the apparatus
should be adapted to the smaller gas volumes involved
Stam H, Van der Beek A, Grünberg K, De Ridder MAJ, De Jongste JC, Versprille A: A rebreathing method to determine carbonmonoxide
diffusing capacity in children: Reference values for 6–18 year olds and validation in adult volunteers. Pediatr Pulmonol 1998;25:205–212.
Indications
The main clinical indications to assess diffusing capacity in childhood are limited

• Monitoring during and after Treatments That Are Toxic to the Lungs
• Diagnosis, Monitoring and Follow-Up of Patients with Chronic Interstitial Lung Disease
• Monitoring of Children with Pulmonary Bleeding Disorders
• Assessment of Functional Impairment in Children with
• Progressive Thoracic Cage Deformities and/orNeuromuscular Disease
• Long-Term Follow-Up Evaluation of Lung Function in Children after Prematurity, Lung Damage
due to Intensive Care and Artificial Ventilation, Severe Pneumonia, or Congenital Malformations
of the Lungs
Indications
Monitoring during and after Treatments That Are Toxic to the Lungs

• Chemotherapy, especially with bleomycin used for treatment of Hodgkin’s

lymphoma or bone tumors. A dramatic reduction in TLCO may occur during the
course.
• Very little is known about reversibility of such toxic effects in children.
• Adjustment of the treatment protocol may be necessary.
• Important pitfall - children who undergo chemotherapy have varying hemoglobin
levels, which may affect the diffusing capacity. Appropriate corrections should be
made.
• Other drugs affecting diffusing capacity - methotrexate, nitrofurantoin, sulfa-
containing products, azathioprine, penicillamine and cyclophosphamide
Indications
Monitoring during and after Treatments That Are Toxic to the Lungs

• Radiotherapy – radiation induced lung damage leads to progressive and

irreversible diffusion impairment.
• Systemic treatment for autoimmune and rheumatic diseases
• Immunosuppressive regimens used after organ transplant have been associated
with severe obstructive and restrictive lung disease.
Indications
Diagnosis, Monitoring and Follow-Up of Patients with Chronic
Interstitial Lung Disease

• The diffusing capacity is one of the early signs of disease, and an important
indicator of progression and treatment effects.
- Interstitial fibrosis syndromes
- Extrinsic allergic alveolitis
- Systemic lupus erythematosus
- Pulmonary vasculitis syndromes
Indications
Monitoring of Children with Pulmonary Bleeding Disorders

- Primary pulmonary hemosiderosis

- Goodpasture syndrome
- Wegener’s disease

• An increase in diffusing capacity predicts a relapse or indicates ongoing disease

• In the long term, therapy resistant hemosiderosis leads to fibrosis and restrictive
lung disease, with impaired diffusing capacity when there is no active bleeding .
Indications
Assessment of Functional Impairment in Children with Progressive
Thoracic Cage Deformities and/orNeuromuscular Disease

• In such children, diffusing capacity may be wrongly interpreted as preserved

despite a low lung volume
• In long-standing restriction, the lung tissue may adapt and diffusing capacity per
unit lung volume may decrease.
Indications
Long-Term Follow-Up Evaluation of Lung Function in Children after
Prematurity, Lung Damage due to Intensive Care and Artificial
Ventilation, Severe Pneumonia, or Congenital Malformations of the
Lungs

- Bronchopulmonary dysplasia
- Meconium aspiration
- Congenital diaphragmatic hernia
- Lung cysts
Thank you