Single-breath transfer factor in young healthy adults: 21% or 17.5% inspired oxygen?

For the measurement of the single-breath transfer factor of the lung for carbon monoxide (TL,CO,sb), the American Thoracic Society (ATS) recommends using a test gas with a 21% inspired fraction of oxygen (FI,O2) whereas the European Respiratory Society (ERS) expressly recommends 17-18% FI,O2. The ERS committee argues that with a higher concentration (e.g. 21%) the alveolar fraction of oxygen (and accordingly TL,CO,sb) "varies with the volume of the test gas which is inspired", that is, presumably, in proportion to the volume of the test gas that is diluted in the alveolar volume. The current study measured TL,CO,sb and the transfer coefficient (KCO,sb) in duplicate in 67 healthy adults (age 17-23 yrs) using, in random order, an inspired gas containing either 17.5% or 21% oxygen. A correction was applied for carboxyhaemoglobin, in line with ATS recommendations. As expected, TL,CO,sb was higher with 17.5% FI,O2 test gas compared with 21% FI,O2 test gas (11.98 +/- 2.68 versus 11.38 +/- 2.56 mmol x min(-1) x kPa(-1), respectively) as well as KCO,sb (1.98 +/- 0.24 versus 1.90 +/- 0.23 mmol x min(-1) x kPa(-1), respectively). The ratio of TL,CO,sb measurements was strictly independent of the residual volume/total lung capacity ratio measured with plethysmography. Hence, the rationale used by the European Respiratory Society, which utilises a 17-18% inspired fraction of oxygen test gas for single-breath transfer of the lung for carbon monoxide measurements, would appear to be unwarranted in young healthy adults.