SPLIT LUNG FUNCTION TEST

• This nuclear medicine procedure is done to

evaluate resectability of lung tissue on patients
with lung carcinoma or lung transplant
– The concern relates to whether or not there is
enough viable lung tissue following the removal of
cancerous lung tissue
– The rationale to perform the thoracotomy is based
on:
• Resecting the tumor
• Patient's ability to tolerate the surgical results
• Regional Perfusion Test - Intravenous injection of insoluble
radioactive xenon (133Xe). The peak radioactivity of each
lung is proportional to the degree of perfusion of each lung.
• Regional Ventilation Test - Using an inhaled, insoluble
radioactive gas (Xenon, 99m-technetium), the peak
radioactivity over each lung is proportional to the degree of
ventilation.
• Combining radiospirometry with whole-lung testing (FEV1,
FVC, maximal breathing capacity) has resulted in a fair
degree of correlation between predicted volumes and
pulmonary function tests measured after pneumonectomy.
• It should also be noted that a split lung procedure is
very non-specific in finding lung cancer and it is
unable to identify metastatic involvement
• The study is combined with pulmonary lung function
test
– Forced expiratory volume in time (1 - 3 seconds) - FEV1
– Forced vital capacity (FVC) - volume of air forced out of
lung
– Study should be done when the patient is not on a
bronchodilator
• The patient can tolerate significant amount of lung
removal if the pulmonary lung function test meets the
following values:
– FEV1 is greater than 50% of the FVC and the FVC is greater
than 2 L
– Maximum voluntary ventilation is greater than 50% of the
predicted value
– Ratio of residual volume to total lung capacity is less than 50%
• Surgery is usually not performed if the FEV1is below 0.8
L
• When the above criteria is/are not met, a split
lung procedure using 99mTcMAA is usually
ordered
• The procedure is as follows:
– Inject the patient with 4 mCi IV using 99mTcMAA
– Camera setup
• 256 x 256
• LEHR collimator
• 500 to 750k counts per image
• Take anterior and posterior images
• Once the images are collected, ROIs are drawn
over the R and L lungs
DLCO
•  Diffusing capacity (also referred to as transfer factor)
is usually measured using small concentrations of
carbon monoxide (CO) and is referred to as DLCO or
DCO.
• DLCO is used to assess the gas-exchange ability of
the lungs, specifically oxygenation of mixed venous
blood.
• The most commonly used method is the single-
breath, or breath-hold technique. The single-breath
method is also the most widely standardized.
•  DLCO measures the transfer of a diffusion-
limited gas (CO) across the alveolocapillary
membranes.
• DLCO is reported in milliliters of
CO/minute/millimeter of mercury at 0°C, 760
mm Hg
• In the presence of normal amounts of Hb and normal
ventilatory function, the primary limiting factor to
diffusion of CO is the status of the alveolocapillary
membranes.
• This process of conductance across the membranes can
be divided into two components:
– Membrane conductance (Dm) Dm reflects the process of
diffusion across the alveolocapillary membrane.
– The chemical reaction between CO and Hb Uptake of CO by
Hb depends on the reaction rate (θ) and the pulmonary
capillary blood volume (Vc).
• DLCO will be affected by
– Changes in membrane component
– Alterations in Hb
– Capillary blood volume
 Decreases with
• Restrictive Lung diseases
• Asbestosis
• Silicosis
• Idiopathic pulmonary fibrosis
• Sarcoidosis
• Systemic lupus erythematosus
• Inhalation of toxic gases (alveolitis)
• Loss of lung tissue
• Space occupying lesions (tumors)
• Pulmonary edema
• Lung resection
• Radiation therapy (fibrotic changes)
• Chemotherapy
•  DLco sometimes used to differentiate
between emphysema and chronic bronchitis
• In patients with COPD, DLco less than 50% of
predicted indicate O2 desaturation during
exercise
• Low resting DLco (<50% - 60% of predicted)
may indicate the need for assessment of
oxygenation during exercise
INDICATIONS OF DLCO