There is increasing interest in using the Multiple Breath Washout technique and the lung clearance index (LCI) for detecting early pulmonary changes, for example, in cystic fibrosis lung disease. However, there are still limited data regarding equipment specific reference ranges, repeatability and reproducibility. The aim of this prospective study was to assess within-test repeatability, short term reproducibility and long term reproducibility, and to establish normal values for the LCI in healthy children and adolescents using the sidestream ultrasonic flow sensor (EasyOne Pro, MBW Module, ndd Medical Technologies, Switzerland). Fourty-four volunteers (5.3-20.3 years) were recruited for the 1st test. Twenty-two out of 44 were measured on a 2nd test occasion after an interval of 1 hr (2nd test). Thirty-four out of 44 agreed to come back for a follow up test 6-15 months later (3rd test). Mean LCI (SD) was 6.2 (0.4), 6.3 (0.4), and 6.0 (0.4) at the 1st, 2nd, and 3rd test. The upper limit of normal was 7.0 for all subjects. Within-test repeatability was 5.1%. Short-term reproducibility (1st test vs. 2nd test) was 4.2% with a mean difference of -0.13 (95% CI -0.350; 0.087). Long-term reproducibility (1st test vs. 3rd test) was 5.1%, with a mean difference of 0.017 (95% CI -0.016; 0.348). With this low variability of the LCI for both, within and between tests, our study demonstrates reliability and robustness of equipment, protocol and analysis and the reliability of the MBW technique in general. The present data will help to interpret the effect of therapeutic interventions and interpretation of longitudinal data in patients with pulmonary diseases.

Lung clearance index: Normal values, repeatability, and reproducibility in healthy children and adolescents

Measurement of gas flow and airway pressure at the Y-piece of an endotracheal tube provides valuable information about airway integrity and basic pulmonary function [1]. We describe the working principle and design of the D-lite sensor (Datex Division, Instrumentarium Corporation, Helsinki, Finland), which, in a single, lightweight adaptor piece, encloses flow, airway pressure, and sidestream gas measurement. The main emphasis in the design of this instrument was on reliable and accurate operation during continuous monitoring with exposure to humidity and mucus. Therefore, a robust flow-restrictor element with a pick-off arrangement resembling a Pitot tube was employed. This arrangement has nonlinear characteristics with potential difficulties in the measurement of small flows. However, these inherent drawbacks, together with compensations required because of varying gas fractions and pressure, can be handled by sophisticated computer algorithms at the host-monitor end (Capnomac Ultima [Datex Division, Instrumentarium Corporation, Helsinki, Finland]). Validation methods with main results and a brief review of applications are given.

A novel sensor for routine continuous spirometry of intubated patients.

Objective:To measure the pressure-flow relationship of pediatric endotracheal tubes (ETTs) in trachea models, to mathematically describe this relationship, and to evaluate in trachea/lung models a method for calculation of pressure at the distal end of the ETT (Ptrach) by subtracting the flow-depend

Continuous calculation of intratracheal pressure in the presence of pediatric endotracheal tubes.

Over recent years, there has been renewed interest in the multiple breath wash-out (MBW) technique for assessing ventilation inhomogeneity (VI) as a measure of early lung disease in children. While currently considered the gold standard, use of mass spectrometry (MS) to measure MBW is not commercially available, thereby limiting widespread application of this technique. A mainstream ultrasonic flow sensor was marketed for MBW a few years ago, but its use was limited to infants. We have recently undertaken intensive modifications of both hardware and software for the ultrasonic system to extend its use for older children. The aim of the current in vivo study was to compare simultaneous measurements of end-tidal tracer gas concentrations and lung clearance index (LCI) from this modified ultrasonic device with those from a mass spectrometer. Paired measurements of three MBW, using 4% sulfur hexafluoride (SF(6)) as the tracer gas and the two systems in series, were obtained in nine healthy adult volunteers. End-tidal tracer gas concentrations (n = 675 paired values) demonstrated close agreement (95% CI of difference -0.23; -0.17%, r(2) = 1). FRC was slightly higher from the MS (95%CI 0.08;0.17 L), but there was no difference in LCI (95%CI -0.10; 0.3). We conclude, that this ultrasonic prototype system measures end-tidal tracer gas concentration accurately and may therefore be a valid tool for MBW beyond early childhood. This prototype system could be the basis for a commercial device allowing more widespread application of MBW in the near future.

http://web.eng.fiu.edu/watsonh/elr4202/References/MultiBrWashOut.pdf

Multiple breath washout with a sidestream ultrasonic flow sensor and mass spectrometry: A comparative study†‡

Objective

Inert gas multiple breath washout (MBW) for measuring Lung Clearance Index using mass spectrometry and 4% sulfur hexafluoride (SF6) as the tracer gas has been shown to be sensitive for detecting early Cystic Fibrosis (CF) lung disease. However, mass spectrometry requires bulky equipment and is expensive to buy and maintain. A novel sidestream ultrasonic device may overcome this problem. The aims of this study were to assess the feasibility and clinical validity of measuring lung volume (functional residual capacity, FRC) and the LCI using the sidestream ultrasonic flow sensor in children and adolescents with CF in relation to spirometry and plain chest radiographs.



Patients and Methods

MBW using the sidestream ultrasonic device and conventional spirometry were performed in 26 patients with CF and 22 healthy controls.



Results

In the controls (4.7–17.7 years) LCI was similar to that reported using mass spectrometry (mean (SD) 6.7 (0.5)). LCI was elevated in 77% of the CF children (6.8–18.9 years), whereas spirometry was abnormal in only 38.5%, 61.5%, and 26.9% for FEV1, MEF25, and FEV1/FVC, respectively. This was more marked in children <10 years. LCI correlated with the Crispin-Norman score, whereas FEV1 did not.



Conclusions

Sidestream ultrasonic MBW is a valid and simple alternative to mass spectrometry for assessing ventilation homogeneity in children. Pediatr Pulmonol. 2008; 43:731–738. © 2008 Wiley-Liss, Inc.

A Novel Sidestream Ultrasonic Flow Sensor for Multiple Breath Washout in Children

The construction and specific function of a new ultrasonic flowmeter are described. The mean velocity of the respiratory air flow is calculated by measuring the transit times of short ultrasonic pulse-trains simultaneously transmitted upstream and downstream at a 650 Hz rate. The flowmeter system consists of a control unit and a separate flowhead. The former includes the power supplies, a controlling microprocessor, most of the signal processing circuitry, and three analog outputs for flow, volume, and temperature, respectively. The flowhead contains the respiratory tube with a constant circular cross section (length 90 mm, diameter 20 mm, dead space 35 cm3), a fast temperature sensor, two electronic circuits for processing of flow and temperature data, and a sound transmission channel with two capacitive ultrasonic wide-band transducers. This respiratory air flowmeter is extremely fast (response time 1-2 ms) and accurate, with low noise (below 9ml/s), with a wide flow range (bidirectional from 0 to 9 l/s) and with a linear frequency response up to 70 Hz.

Peter Pietsch

Papers

Design and Construction of a Pulsed Ultrasonic Air Flowmeter