Oxygen transport between the lungs and the body depends on numerous complex factors. Ventilation and the alveolar-capillary surface area are of course important but a critical component is hemoglobin. Oxygen is poorly soluble in water (which is what blood is mostly made of) and the transportation of oxygen throughout the body would not happen without hemoglobin’s ability to absorb and release oxygen on demand. Although it is possible to measure the diffusing capacity of oxygen (DLO2) the process is technically difficult and not at all suited to routine clinical testing.

Recently I was trying to explain the effect of altitude on blood oxygenation to somebody with IPF. They had observed that their oxygen saturation was fairly normal at sea level but that they needed to use their supplemental O2 when they went up to 2000 feet and didn’t understand why such a low altitude made that much of a difference. I don’t think I did very well with the explanation since at the time I was limited to only text and I much prefer pulling out diagrams and waving my hands in the air.

My lab is in the final stages of a software update that will allow for electronic signing of our reports. This has been a long and slow process partly because the release date of the software got pushed back several times but mostly because a wide variety of different hospital departments and sub-departments have had to be involved. In all the years that I’ve had computers in the pulmonary function lab I’ve never gone through a software update that was either as easy as expected or occurred within the original schedule. This includes the time when all we had was a single IBM PC/AT with a 40 megabyte hard drive, no network and the only people that cared we were going through an update was ourselves. Since we now have a dozen networked PCs located in two different building on-campus as well as three off-site locations using an IS-managed SQL server and HL7 interface I didn’t have any expectations for a speedy update and so far I have not been disappointed.

There are at least a half dozen companies that use an ultrasonic flowmeter in their spirometer. The first patent for an ultrasonic flowmeter was made in the 1970’s but it wasn’t until the 1990’s that the first ultrasonic spirometers came to market. The basic idea is fairly simple and that is to measure the transit time of ultrasonic pulses through flowing gas. Pulses that travel in the same direction the gas is flowing will take less time to travel a given distance, while pulses traveling against the direction of gas flow take a longer time.

Sooner or later we all get lucky and find ourselves able to replace older equipment. When you have equipment that’s so old it can’t be repaired (either because the manufacturer no longer supports it or because the manufacturer no longer exists), you’d think this would be a no-brainer but money is always in short supply. I’ve often had to try to keep equipment running long past its expected life time and was only allowed to replace it when it finally broke beyond all hope of repair.

A lab manager recently emailed me and asked my opinion about whether it was okay to use generic mouthpiece filters on their test systems. They had asked the same question of their equipment manufacturer and received the following statement (parts of which have been redacted by me): “The [model number] PFT system was designed/tested/certified using the [manufacturer’s] filter. While other “off-label” filters may fit our devices, they have never been tested or approved for use by [the manufacturer]. The precision and accuracy of our devices could be compromised by using different type filters. It is our recommendation that you continue to use the [manufacturer’s] approved filters with your PFT equipment.”

While reviewing a CPET I noticed the patient had a low PETCO2 throughout exercise and an elevated Ve-VCO2 slope. In addition the patient’s minute ventilation was on the high side (75% of predicted) at peak exercise. This is something you might expect to see in association with pulmonary vascular disease but the subject had a normal DLCO; normal spirometry; their oxygen saturation was normal at all times; and they had a normal maximum VO2 and a normal VO2 at anaerobic threshold. Since there didn’t seem to be any clinical reason for the low PETCO2 I had to wonder whether it was due to hyperventilation syndrome (HVS).

Once again my lab was questioned by a research study’s primary investigator and study coordinator about why our lung volume results came out significantly lower than another lab’s. In order to be part of this study a subject has to have an RV that is greater than 150% of predicted. The RV we had obtained on a subject referred to the study was over a liter less than the results they had brought with them from another lab and for this reason the patient no longer qualified.

Last week I was discussing the use of DL/VA to differentiate between the different causes of gas exchange defects with a physician. DL/VA is DLCO divided by the alveolar volume (VA). It is an often misunderstood value and the most frequent misconception is that it is a way to determine the amount of diffusing capacity per unit of lung volume (and therefore a way to “adjust” DLCO for lung volume). This is not the case because dividing DLCO by VA actually cancels VA out of the DLCO calculation and for this reason it is actually an index of the rate at which carbon monoxide disappears during breath-holding.

Oddly enough, I recently got a couple emails on the same day about the FEF25-75 and ended up corresponding for a while with the authors. FEF25-75 is a subject that somehow manages to keep resurrecting itself no matter how many stakes have gotten hammered into its heart. My opinion (expressed previously ), and those of many others, is that the measurement of FEF25-75 is overly affected by FVC volume and expiratory time; that its reproducibility is poor; that its “normal” range is too broad to be meaningful; and that the FEF25-75 is usually only abnormal when the FEV1 is also below the LLN. Despite all this the FEF25-75 still continues to be used by many clinicians and researchers.