Taibah University

College of Medical Rehabilitation Sciences

Respiratory Therapy Department
Advanced Pulmonary Function Testing (RT 477)
Year 1443

Gas Dilution Method

1444/2022
Gas dilution
• Gas used: Nitrogen or helium
• Technique: Single breath or multiple breath test
• Technique: open circuit (N2) or closed circuit (He)
1- Closed circuit -multiple breath
helium dilution test
• Gas dilution is a method of determining lung volumes that cannot be
determined from simple spirometry. These include functional residual
capacity, which is computed directly, and residual volume and total lung
capacity, which are computed from FRC. The subject is connected to a
spirometer containing a known concentration of helium, or some other inert
and insoluble gas.
• After several minutes of breathing, the helium concentrations in the
spirometer and lung become the same. From the law of conservation of
matter, we know that the total amount of helium before and after is the
same. Therefore we can set the fractional concentration times the volume
before equal to the fractional concentration times the volume after, because
of the conservation law of matter.
• F1V1=F2(V1+V2) We solve for the volume after (the volume of the lung
and spirometer), subtract out the volume of the spirometer, and we get the
volume of the lung.
Closed circuit -multiple breath helium
dilution test
Closed circuit multiple breath helium
dilution test
• Along with body plethysmography, the gas dilution method is the most
commonly used method of determining lung volumes.
• It is usually based on the use of a tracer gas (such as helium) that is inhaled in a
defined concentration until equilibration is reached, and then measured again in
expiration.
• The degree of dilution allows calculation of the volume of gas that has been
interacting with the inhaled gas in the lung.
• The method requires the tracer gas to be inert and insoluble, so that minimal
amounts of it diffuse into the lung parenchyma and the blood.
• The gas dilution method facilitates determination of FRC.
• An alternative way to determine lung volumes uses nitrogen in an elimination
technique.
• It can only measure lung volumes in communication with conducting airways
Principle
• For the gas dilution method, the patient starts to breathe
the test gas (usually a mixture of 10%helium, 25–30%oxygen
(O2) and balanced nitrogen is used to fill the circuit system)
at the end of a normal tidal expiration and is then instructed
to breathe with regular tidal breaths. TheO2 flow is adjusted
to compensate for O2 consumption, as significant errors in
the calculation of FRC levels can result if it is not adequately
accounted for. The helium concentration is noted
periodically and helium equilibration is considered to be
complete when the change in helium concentration
becomes minimal over a period of approximately 30
seconds. Equilibration will take longer in very obstructed
patients, and may take as long as 10minutes in patients with
severe gas-exchange abnormalities.
• In normal subjects there is relatively good agreement
between measurements using the helium dilution method
and body plethysmography.
• In chronic obstructive pulmonary disease (COPD), particularly
if this is moderate to severe, the differences between FRC
and ITGV increase significantly as the inert gas fails to reach
all lung areas (this can be more than 600 mL) and therefore
may significantly underestimate lung volumes. This effect is
particularly marked in bullous emphysema, when the bullae
have little connection to the airway. However, if enough time
is allowed for gas equilibration, the FRCHe–ITGVBody
difference can be minimized in most obstructed patients.
Obstruction or bullous disease can have trapped,
noncommunicating air within the lungs
FRC may be measured as being less than its actual volume
Gas dilution wash out test
Advantage
• Simple
• Easy
• Requires less effort to perform
• Acceptable method for
measuring lung volumes
• Useful in detection of airtrapping
• Requires only tidal breathing so
minimal patient effort
• Instrumentation is simple and
inexpensive
Disadvantage
• require gas supplies, appropriate analysers
• Requires a long period of rebreathing, which
can be demanding for patients.
• The most important limitation is the fact that
tracer gases (usually helium and nitrogen)
may not reach the more poorly ventilated
regions of the lung in patients with more
severe chronic airway obstruction, and this
results in underestimation of lung volumes.
So it can underestimate FRC in obstructive
lung disease so can be interpreted as mixed
pattern (obstructive and restrictive) as not
include areas with airtrapping
• Commercial systems frequently limit
equilibration time to no more than 4 to 5
minutes.
 Helium dilution method
principle
• “Equilibriation of gas in the lung with a
known value of gas containing helium”
• If a gas with known He concentration is
breathed in, the He will be diluted by the
He-free gas within the lungs
• If the expired He concentration is monitored
the volume of gas within the lungs can then
be calculated from the dilution effect.
• Once the He reaches equilibrium between
the spirometer and the patient, the final
concentration of He is recorded
• The FRC can then be calculated
• Also should be corrected to BTPS conditions
Closed circuit helium dilution test procedure

• Patient preparation
• Checked for a perforated eardrum (if so, an earplug should be used)
• Seated comfortably, with no need to remove dentures
• Procedure is explained, emphasising the need to avoid leaks around the
mouthpiece during the test and to use a nose clip
• Test
• Circuit is flushed with air
• Oxygen is subsequently added to raise the final oxygen concentration to about 25-
30% • Helium meter reading adjusted to zero, helium is added to raise the helium
concentration to nearly full scale deflection (10%) on the analyser
• The patient breathes for 30-60 s on the mouthpiece to become accustomed to the
apparatus, and to ensure a stable end-tidal expiratory level
• The patient is turned ‘‘in’’ (i.e. connected to the test gas) at the end of a normal
tidal expiration and instructed to breathe regular tidal breaths
• Once the helium equilibration is complete, the patient is turned ‘‘out’’ (i.e.
disconnected from the test gas) of the system
 Closed circuit helium dilution
test procedure
As the patient rebreathes from the closed circuit, the blower circulates the gas mixture.
The CO2 is absorbed by soda lime (CO2 absorber), while O2 is added through a valve and
flowmeter at a rate corresponding to the subject’s O2 consumption. As the helium, which
was at first contained entirely within the apparatus, mixes with air contained in the lungs,
its concentration, as monitored by the helium analyzer, falls. Stabilization of the helium
concentration, indicated by a rate of change in concentration of less than 0.02% over a 30-
second interval, signals the point at which the helium concentration has equilibrated
throughout the lung-breathing circuit system; equilibration, the end-point of the test,
occurs within 7 minutes in normal persons. However, in patients in whom the distribution
of ventilation is abnormal – for example, those with chronic obstructive pulmonary
disease (COPD)– equilibration may take much longer. Upon equilibration, the following
equation, based on the law of conservation of mass, is applied :
 Closed circuit helium dilution
test procedure….continue
The initial volume of the system is
the volume of the spirometer and
circuit tubing, whereas the final
volume consists of the initial
volume plus FRC. The latter value is
the only unknown in the preceding
equation. Corrections are usually
made for the small amount of
helium dissolved in body tissues
during the test
 Closed-Circuit Helium Dilution test

FRC = (%HeInitial - %HeFinal) x System volume

%HeFinal
Normal value : Equilibrium at = 7 minutes is normal FRC.
If Equilibrium takes longer = up to 20 minutes it indicates obstructive disease.
Important notes
CO2 and water absorbers
• CO2 and water to be removed before the sample is
introduced into helium analyser
• Soda lime canister is mounted vertically to ensure
uniform distribution of the granules for absorbing
CO2
• The canister should be changed after every 20
determinations or when the CO2 concentration in
the circuit rises above 0.5% to avoid patient
discomfort and hyperventilation
Important notes
Volume Corrections
• A volume of 100 ml is sometimes subtracted from the FRC
to correct loss of He to the blood
• The dead space volume of the breathing valve and filter
should be subtracted from the FRC
Acceptability
• Spirometer tracing should indicate no leaks (detected by a sudden
decrease in He), which would cause an overestimation of FRC
• Test is successfully completed when He readings change by less than
0.02% in 30 seconds or until 10 minutes has elapsed
• Multiple measurements of FRC should agree within 10%
• The average of acceptable multiple measurements should be reported
• Factors that lead to unsatisfactory manoeuvres include cough, glottal
closure, gas leak from the nose or mouth and too brief effort
• Largest of the three satisfactory IVC manoeuvres should be reported
• RV = FRC – ERV
• TLC = RV + IVC
Loss of Helium / leaks
• Lead to over estimation of FRC
• Continued helium loss leads to failure to achieve
equilibration – Equipment leaks – Leaks around the
nose clip and mouthpiece – Transfer through
ruptured tympanic membranes – Swallowing and
absorption into the fluids and tissues of the body R
• The effect of He absorption is a small
He dilution in mechanically
ventilated
• An increase in FRC is the goal of therapy with
positive end-expiratory pressure (PEEP) in ARDS
• Useful in determining the efficacy of a particular
level of PEEP
• Allows reliable, simple, and reproducible
measurements of lung volume in mechanically
ventilated ALI/ARDS patients
2- Single breath tests -Helium
• Performed almost exclusively in conjunction with
the determination of the transfer factor of the lung
for CO (test for diffusion capacity will be discussed
later)
• Not recommended for routine use, unless in
connection with the determination of the effective
TLCO when screening large numbers of subjects
3- Multiple breath nitrogen
Washout method (open circuit)
Nitrogen is present in the lung in a known
concentration (∼80%).
During the nitrogen washout technique for
measuring FRC, nitrogen is washed from the patient
lungs using a one-way flow of 100% oxygen by the
mouth.
The total amount of nitrogen washed from the lungs
provides a measure of the patient's resting FRC.
Multiple breath Nitrogen
Washout
• Open circuit method
• Patient breathes
100% oxygen while
the nitrogen washed
out of the lungs is
measured
• Assumes 80% of lung
volume is nitrogen
• Several “problems” with
this test
Multiple breath nitrogen
washout test Principle
• This technique is based on washing out the N2 from
the lungs, while the patient breathes 100% O2.
• The initial alveolar N2 concentration and the
amount of N2 washed out can then be used to
calculate the lung volume at the start of washout.
The technique originally utilised gas collections for
a 7-min period, a period adequate for washout of
N2 from the lungs of healthy subjects.
Multiple breath nitrogen
washout test
The subject breathes on a mouthpiece that, at the
end of a relaxed tidal exhalation, is connected to an
inspiratory source of 100% oxygen for about 7
minutes.
while the subsequent exhaled gas is directed by one-
way valves into a collection bag, previously flushed
with oxygen so that it contains no nitrogen.
The resident nitrogen is washed out of the lungs
progressively and monitored with continuous
analysis at the mouthpiece.
Multiple breath nitrogen
washout test technique
When the exhaled nitrogen concentration falls
below 2%, the test is terminated, and the
volume of nitrogen collected is measured.

The FRC can be calculated on the basis that this

nitrogen volume represents 80% of the lung gas
contained at the beginning of the test.

Washout can be completed in 3 to 4 minutes in

normal subjects but may require longer than 15
minutes with severe obstructive airway disease
Nitrogen washout test
Measurement
• 1) The equipment should be turned on and allowed an adequate warm-up time, with calibration as
instructed by the manufacturer.
• 2) The patient should be asked if he/she has a perforated eardrum (if so, an earplug should be used).
• 3) The patient is seated comfortably, with no need to remove dentures. The procedure is explained,
emphasising the need to avoid leaks around the mouthpiece during the washout and using a nose
clip.
• 4) The patient breathes on the mouthpiece for ,30–60 s to become accustomed to the apparatus,
and to assure a stable end-tidal expiratory level.
• 5) When breathing is stable and consistent with the end-tidal volume being at FRC, the patient is
switched into the circuit so that 100% O2 is inspired instead of room air.
• 6) The N2 concentration is monitored during the washout. A change in inspired N2 of .1% or sudden
large increases in expiratory N2 concentrations indicate a leak; hence, the test should be stopped
and repeated after a 15-min period of breathing room air.
• 7) The washout is considered to be complete when the N2 concentration is ,1.5% for at least three
successive breaths. 8) At least one technically satisfactory measurement should be obtained. If
additional washouts are performed, a waiting period of o15 min is recommended between trials. In
patients with severe obstructive or bullous disease, the time between trials should be o1 h . If more
than one measurement of FRCN2 is made, the value reported for FRCN2 should be the mean of
technically acceptable results that agree within 10%. If only one measurement of FRCN2 is made,
caution should be used in the interpretation.
Normal range
The normal amount of nitrogen remaining in the lung
is less than 2.5%.

If greater than 2.5% nitrogen remains at 7 minutes,

this indicates :
1- poor distribution of ventilation.
2- obstructive disorder.
3- possible pulmonary embolism.
 Multiple breath Nitrogen Washout
(open circuit)-summary

Less than 8 minutes to reach less than 2.5% nitrogen in lungs.

Indicate normal FRC.
Patient breathes 100% O2 for about 7 minutes, exhaling all gas
into an analyzer, until nitrogen remaining in lungs is less than
2.5%. Then patient exhales completely. Fractional concentration
of alveolar nitrogen (FAN2) is noted, and FRC is computed.
Greater than 7 minutes to reach 2.5% nitrogen remaining in
lungs indicates poor distribution of ventilation, obstructive
disorder, or possible pulmonary embolism. Calculated FRC
increased in obstructive disease, decreased in restrictive disorder.
4- Single-Breath Nitrogen Washout [SBN2
(SBO2)]
It measures
• Distribution of Ventilation

• Closing Volume

• Closing Capacity

• Deadspace
Single-Breath Nitrogen Washout (SBN2)

Procedure

• Patient exhales to RV
• Inspires a VC breath of 100% O2
• Patient exhales slowly and evenly
(0.3-0.5L/s) until feels lung is
empty
• The exhaled gas passes through
N2 analyzer that measures the
change in concentration of
nitrogen
• N2 concentration is plotted
against volume
 Single-Breath Nitrogen Washout
(SBN2)
• Phase I: upper airway gas from
anatomical dead space (VDanat),
consisting of 100% O2
• Phase II: mixed airway gas in which the
relative concentrations of O2 and N2
change abrubtly as VDanat volume is
expired
• Phase III: a plateau caused by the
exhalation of alveolar gas in which
relative O2 and N2 concentrations
change slowly and evenly

• Phase IV: an abrupt increase in the

concentration of N2 that continues until
RV is reached
Single-Breath Nitrogen Washout (SBN2)

% N2 750 – 1250

Is 1.5% or less in healthy adults; up

to 3% in older adults

Increased % N2 750 – 1250 is

found in diseases characterized by
uneven distribution of gas during
inspiration or unequal emptying
rates during expiration.

Patients with severe emphysema

may exceed 10%
 Single-Breath Nitrogen Washout (SBN2)
Slope of Phase III is an index of gas
distribution
Values in healthy adults range from
0.5% to 1.0% N2/L of lung volume
Single-Breath Nitrogen Washout (SBN2)
Closing Volume
The onset of Phase IV marks
the lung volume at which
airway closure begins
In healthy adults, airways begin
closing after 80-90% of VC has
been expired, which equates to
30% of TLC
Reported as a percentage of VC
Closing Capacity
If RV has been determined, CV
may added to it and expressed
at Closing Capacity (CC)
CC is recorded as a percentage
of TLC
Single-Breath Nitrogen Washout
(SBN2)
• A phase III N2 rise > 1.5% indicates uneven
distribution of ventilation or uneven flow rates, with
possible pulmonary embolism.
• CV is Phase IV. CV should = 10-20% of VC. CC is
Phase V. CC should = 30-40% of TLC. CV%
increased in small airway obstruction. Very
sensitive for detecting early airway closure
Single-Breath Nitrogen Washout
(SBN2)

CV and CC may be increased,

indicating earlier onset of
Normal Values for CC and CV airway closure in:
_______________________ • Elderly patients
Male Female • Smokers, early obstructive
disease of small airways
• Congestive heart failure when the
CV/VC% 7.7% 8.7% caliber of the small airways is
compromised by edema
CC/TLC % 24.8% 25.1%
Single-Breath Nitrogen Washout
(SBN2)

• Acceptability Criteria

• Inspired and expired VC should be within 5%or 200 ml

• The VC during SBN2 should be within 200 ml of a previously
determined VC
• Expiratory flows should be maintained between 0.3 and 0.5
L/sec.
Single-Breath Nitrogen Washout
(SBN2)
Advantages
• The most widely used is
the N2 SBW test
• assess ventilation
distribution inhomogeneity
at differing lung volumes
• Simple
• Inexpensive
• Less patient cooperation
Disadvantages
• washout takes a
long time and,
• it does not estimate
the volume of poorly
ventilated regions of
the lung.
Example of a typical single-breath washout (SBW) trace. Nitrogen gas (N 2) expirogram
showing calculation of phase III slope (SIII) in a vital capacity SBW test in a 60-yr-old
smoker. SIII is calculated between 25% and 75% of the expired volume (S III 4.4%·L−1),. The
four phases of the expirogram are also demonstrated: phase I (absolute dead space), phase
II (bronchial phase), phase III (alveolar phase) and phase IV (fast rising phase at end of
expiration). Closing volume (CV) is the expired volume (L) from the start of the upward
deflection where phase IV starts, to the end of the breath. If residual volume (RV) is
known, closing capacity (CC) can be calculated: CC = CV+RV.