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Fixed breathing protocols in multiple-breath-washout testing: truly an option in children?

Anne-Christianne Kentgens, Philipp Latzin, Sophie Yammine
European Respiratory Journal 2021 57: 2100001; DOI: 10.1183/13993003.00001-2021
Anne-Christianne Kentgens
Division of Respiratory Medicine, Dept of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
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Philipp Latzin
Division of Respiratory Medicine, Dept of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
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Sophie Yammine
Division of Respiratory Medicine, Dept of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
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  • For correspondence: Sophie.Yammine@insel.ch
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Abstract

Direct extrapolation of fixed breathing pattern recommendations for multiple breath washout in healthy adults to children and patients with lung disease requires caution https://bit.ly/39vVGSK

To the Editor:

We read with much interest the study by Verbanck et al. [1], which showed that multiple breath washout (MBW) protocols with fixed tidal volume (VT) ranges tend to decrease acinar and conductive airway ventilation heterogeneity (Sacin and Scond) variability, improve VT normalisation methods and shorten test duration in healthy adults. However, we question whether direct extrapolation of the results of Verbanck et al. [1] to children and subjects with lung disease, as suggested by the authors, is appropriate.

We agree with Verbanck et al. [1] that the mean VT of 9 mL·kg−1 in natural breathing and 16 mL·kg−1 in 1 L fixed breathing protocol, as seen in their study, overlaps with the recommended range of 10–15 mL·kg−1 in children [1, 2]. However, depending on their age and thus their natural VT, adopting 1 L fixed breathing protocols in children forces them to breathe beyond their natural VT range. In 1 L fixed breathing protocol, a 5-year-old boy of 20 kg needs to maintain a VT of 50 mL·kg−1. This is nearly five times the natural VT. Even a 14-year-old adolescent of 40 kg needs to maintain a VT of 25 mL·kg−1, which is clearly higher than the upper end of the recommended VT range in children [2–5]. Thus, by nature, the 1 L fixed breathing protocol demands higher VT per kilogramme ratios in children than in adults and it will force children to breathe in a non-physiological VT range. In longitudinal studies throughout childhood, the natural VT range will change with growth and might further complicate comparison over time when applying 1 L fixed breathing protocol.

This leads to the question whether MBW with 1 L fixed breathing protocol reflects ventilation distribution in children and lung disease adequately. Yammine et al. [4] showed that application of the 1 L fixed breathing protocol induced heterogeneous changes of the lung clearance index (LCI) with an overall increase of LCI in healthy children and children with cystic fibrosis compared to natural VT. In this study population, 1 L fixed breathing protocol led to a clear overestimation of ventilation inhomogeneity. Thereby, the changes seen in the natural breathing pattern induced by the 1 L fixed breathing protocol were highly complex, which was reflected by very heterogeneous changes [3, 5]. In lung disease, additional pathophysiological factors may further add to the complexity. Factors such as hyperinflation or non-ventilated lung areas influence natural tidal breathing and the individual's possibility to adapt the breathing pattern to the 1 L fixed breathing protocol. Thus, the effect on MBW results in lung disease are even more unpredictable.

While one of the goals of the 1 L fixed breathing protocol in adults is to decrease breathing variability, in children variability of tidal breathing has shown to be an expression of the normal physiological capacity of the lung and its adaption to external stimuli [6]. This further raises the question how representative MBW measurements with suppressed natural breathing variability really are to assess ventilation inhomogeneity, especially in younger children.

In conclusion, we believe one should be cautious to apply breathing pattern recommendations derived from a study in healthy adults to children and patients with lung disease.

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Footnotes

  • Conflict of interest: A-C. Kentgens has nothing to disclose.

  • Conflict of interest: P. Latzin reports personal fees from Gilead, Novartis, OM Pharma, Polyphor, Roche, Santhera, Schwabe, Vertex, Vifor and Zambon, and grants from Vertex, all outside the submitted work.

  • Conflict of interest: S. Yammine has nothing to disclose.

  • Support statement: The work was supported by Swiss National Science Foundation grant number 179905 to Sophie Yammine and 182719 to Philipp Latzin. Anne-Christianne Kentgens is a recipient of the Swiss Government Excellence Scholarship from The Swiss Confederation. Funding information for this article has been deposited with the Crossref Funder Registry.

  • Received January 1, 2021.
  • Accepted January 3, 2021.
  • ©The authors 2021. For reproduction rights and permissions contact permissions{at}ersnet.org
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References

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    1. Verbanck S,
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    Mitigating increased variability of multiple breath washout indices due to tidal breathing. Eur Respir J 2021; 57: 2002765. doi:10.1183/13993003.02765-2020
    OpenUrlAbstract/FREE Full Text
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    1. Robinson PD,
    2. Latzin P,
    3. Verbanck S, et al.
    Consensus statement for inert gas washout measurement using multiple- and single- breath tests. Eur Respir J 2013; 41: 507–522. doi:10.1183/09031936.00069712
    OpenUrlAbstract/FREE Full Text
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    Effect of changes in tidal volume on multiple breath washout outcomes. PLoS One 2019; 14: e0219309. doi:10.1371/journal.pone.0219309
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    1. Yammine S,
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    Impact of different breathing protocols on multiple-breath washout outcomes in children. J Cyst Fibros 2014; 13: 190–197. doi:10.1016/j.jcf.2013.08.010
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    Normative data for multiple breath washout outcomes in school-aged Caucasian children. Eur Respir J 2020; 55: 1901302. doi:10.1183/13993003.01302-2019
    OpenUrlAbstract/FREE Full Text
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Fixed breathing protocols in multiple-breath-washout testing: truly an option in children?
Anne-Christianne Kentgens, Philipp Latzin, Sophie Yammine
European Respiratory Journal Mar 2021, 57 (3) 2100001; DOI: 10.1183/13993003.00001-2021

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Fixed breathing protocols in multiple-breath-washout testing: truly an option in children?
Anne-Christianne Kentgens, Philipp Latzin, Sophie Yammine
European Respiratory Journal Mar 2021, 57 (3) 2100001; DOI: 10.1183/13993003.00001-2021
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