Diffusing Capacity of the Lung for Carbon Monoxide in Mexican/Latino Children. Quality Control and Reference Values

Ann Am Thorac Soc. 2019 Feb;16(2):240-247. doi: 10.1513/AnnalsATS.201712-922OC.


Rationale: Single-breath diffusing capacity of the lung for carbon monoxide (DlCOsb) values are used to evaluate gas exchange; however, the quality of maneuvers performed by children has not been evaluated, and reference values for young people living at moderate altitudes are not well established.

Objectives: Our objectives were 1) to determine whether DlCOsb maneuvers performed by a pediatric population would meet 2017 European Respiratory Society/American Thoracic Society (ERS/ATS) quality control standards; and 2) to report normal DlCOsb values for Mexican/Latino children and adolescents living at moderate altitudes.

Methods: This study involved healthy young people 4-20 years of age from the metropolitan area of Mexico City (2,240 m above sea level) who were recruited in schools from July 2014 to August 2017. DlCOsb testing was performed according to the 2005 ATS/ERS standards, and the quality control of each maneuver was analyzed according to the 2017 ERS/ATS standards. We constructed models for DlCOsb with linear and quadratic terms for weight, height, and age as independent variables using shrinkage statistics, variance inflation factors, the Akaike information criterion, and R2 to compare the results of different models.

Results: Results were obtained for 420 individuals (53% boys) with a mean age of 11.7 ± 4.5 standard deviation (SD) years; 47% of maneuvers from children age 4-6 years were grade A (13% grade B), and 90% of those in children older than 13 years were grade A or B. Forty-six percent of the subjects had a DlCOsb repeatability of <1 ml/min/mm Hg. The mean DlCOsb was higher for boys than for girls (32.4 ± 13.6 [SD] vs. 24.1 ± 7.5 ml/min/mm Hg, respectively). The reference equation for boys was DlCOsb = exp(1.63469 + [0.03251 × age] + [0.00846 × height] + [0.00304 × weight]), R2 = 0.87; for girls, the best equation was DlCOsb = exp(1.56516 + [0.0193 × age] + [0.00893 × height] + [0.00273 × weight]), R2 = 0.75. The single-breath transfer coefficient of the lung for carbon monoxide remained constant with age and height, with a lower limit of normal of 6.5 ml/min/mm Hg/L in boys and 5.4 ml/min/mm Hg/L in girls. Measured DlCOsb was higher than predicted by other authors (P < 0.001 by paired t test).

Conclusions: Individuals 4-20 years of age can complete high-quality DlCOsb tests. Children and adolescents living at 2,240 m have higher DlCOsb values than those living at sea level. Reference equations for DlCOsb obtained at sea level are poor predictors of the values measured at moderate altitude.

Keywords: D reference values; Lung Diffusing Capacity; Pulmonary Function Tests; altitude; children.

MeSH terms

  • Adolescent
  • Altitude*
  • Carbon Monoxide / metabolism*
  • Child
  • Child, Preschool
  • Cross-Sectional Studies
  • Female
  • Healthy Volunteers
  • Humans
  • Lung / physiology*
  • Male
  • Mexico
  • Pulmonary Diffusing Capacity*
  • Quality Control
  • Reference Values
  • Regression Analysis
  • Young Adult


  • Carbon Monoxide