Pulmonary & Respiratory Medicine

Measurement of Exhaled Nitric Oxide Using End Tidal Value during Normal Breathing

Abstract

Tawfic S Hakim, George Cremona and Enrico Camporesi

Increased nitric oxide (NO) production in the expired air has been associated with a number of disease conditions and may reflect the severity of inflammation in the lungs. Measurement of exhaled NO concentration has been proposed as a novel clinical tool for assessing airway inflammation and response to drug therapy. In spite of international guidelines aimed at standardizing the measurement of exhaled NO, clinicians remain skeptical due to the necessity of a significant degree of subject collaboration required by the procedure to obtain meaningful measurements. We hypothesized that exhaled NO concentration may be best measured by using end tidal NO concentration during a breath by breath monitoring. We tested laboratory staff and monitored their NO concentration online using a fast response chemiluminescence NO analyzer during normal breathing at rest for 5 minutes. First we confirmed that the NO analyzer was adequately fast to record fully the swings during normal breathing. We then compared the average end tidal NO value (NOet) from 6 to 10 breaths, to the NO value obtained from the plateau from a single slow vital capacity maneuver as recommended by the ATS guidelines (NOplat). End of exhalation was identified using end tidal carbon dioxide measurement. NOet while breathing room air was 24.3 ± 4.2 (SE) ppb and was not significantly different compared to 22.4 ± 2.8 (SE) ppb using NOplat. Additionally breathing high level of NO of up to 88 ppb did not affect either NOet or NOplat significantly suggesting that both measurements are independent of inhaled NO concentration. NO value at end of exhalation was very reproducible from breath to breath and did not require any special effort on the part of the subject. We recommend using NOet measurement instead of the NOplat value that is highly dependent on the exhalation rate and cooperation of the subject. NOet is much easier to record in children, elderly and patients with respiratory disease. The main requirement for measuring NOet is to have a fast response NO analyzer to record the full swings in NO concentration during normal breathing and to have a way of identifying end exhalation.