Standardisation of gas mixtures for estimating carbon monoxide transfer factor

The American Thoracic Society recommends that the inspired concentration used for the estimation of carbon monoxide transfer factor (TLCO) mixture should be 0.25-0.35% carbon monoxide, 10-14% helium, 17-21% oxygen, balance nitrogen. Inspired oxygen influences alveolar oxygen and hence carbon monoxide uptake, such that transfer factor increases by 0.35% per mm Hg decrease in alveolar oxygen. To aid in the standardisation of TLCO either a known inspired oxygen concentration should be used, or TLCO should be corrected to a standard inspired oxygen concentration. The range of gas mixtures used in practice and the implications for cost and accuracy have been investigated.

A questionnaire was sent to 185 respiratory units in the UK requesting information on (1) the method used to estimate TLCO, (2) the manufacturer of the equipment, (3) the mixture used, (4) whether "medical quality" gas was ordered, and (5) the level of satisfaction with supplier service.

Replies were received from 106 units. Most used the single breath breath holding method for which 17 different test mixtures were ordered. One unit also used the single breath exhalation method. Inspired oxygen ranged from 17.94% to 25%, giving a wide variation in alveolar oxygen and hence TLCO. Forty seven units ordered a specific inspired oxygen, the rest ordering "air" as balance. The cost per litre of gas varied greatly, with the mixture 14% helium, 0.28% carbon monoxide, balance air (17.9% oxygen) and 10% helium, 0.28% carbon monoxide, balance air (18.8% oxygen) being cheapest to produce. Ordering a specific inspired oxygen concentration increased the cost. Large cylinders of gas were cheaper for the same mixture. The mixture for the exhalation method was the most expensive. Sixty seven units ordered "medical quality" gas and six assumed this was supplied. Twenty nine (27%) were dissatisfied with their supplier due to (1) poor service, (2) long delivery times, (3) costs, or (4) wrongly labelled cylinders.

It is recommended that two mixtures be available: (a) 14% helium, 0.28% carbon monoxide, balance air for a helium analyser reading up to 15%, and (b) 10% helium, 0.28% carbon monoxide, balance air for lower reading helium analysers. The mixture should be produced under a medical product licence. The advantage of the single exhalation method for routine clinical use needs to be investigated in view of the higher cost of the mixture.