Abstract:
The present invention can provide a system and method for D LCO  quality control testing and can include an apparatus for testing a pulmonary diagnostic device capable of performing single breath carbon monoxide uptake measurement, comprising: a single gas-tight chamber, with a gas port configured to receive gas from or to expel gas to the exterior of the chamber and a partition configured to change the volume of the single gas-tight chamber; the single gas-tight chamber capable of expanding and contracting; a member disposed within the single gas-tight chamber and configured to limit the movement of the partition, the member being adjustable to set a predetermined maximum volume of the single gas-tight chamber and a predetermined volume of D LCO  test gas that the single gas-tight chamber can receive; and an interface configured for the transfer of gas between the pulmonary diagnostic device and the simulation device via the gas port.

Description:
COPYRIGHT 
     A portion of the disclosure of this patent document contains material that is subject to copyright protection. The copyright owner has no objection to the facsimile reproduction by anyone of the patent disclosure, as it appears in the Patent and Trademark Office patent files or records, but otherwise reserves all copyright rights whatsoever. 
     FIELD OF THE INVENTION 
     The present invention relates to quality control of D LCO  equipment. In particular, but not by way of limitation, the present invention relates to systems and methods for ensuring the measurement accuracy of pulmonary testing devices used for single-breath determination of carbon monoxide uptake in the lung. 
     BACKGROUND OF THE INVENTION 
     Current D LCO  simulators require large and expensive dual-syringe devices. For example, the Hans Rudolph D LCO  simulator, as described in U.S. Pat. No. 6,415,642 requires two syringes (3 and 5 liters) that are joined by a manifold via a three-way valve. The manifold is connected to the D LCO  equipment. Prior to the start of the simulation test, the 3-liter syringe is filled with a precision gas mixture emulating typical alveolar gas concentration seen in patients. Using the three-way valve, the 5-liter is connected to the D LCO  equipment while the 3-liter syringe is isolated with the prefilled precision gas mixture. During the inhalation phase of the D LCO  test maneuver, the 5 liter syringe simulates tidal breathing, exhalation to residual volume, and rapid inhalation to TLC. During the breath hold period, the 3-way valve is turned redirecting the D LCO  device to the 3 liter syringe. After the breath hold, the content of the 3-liter syringe is emptied into the D LCO  device. 
     The Hans Rudolph simulator “establishes” approximate target D LCO  values for the D LCO  device under test by controlling the inspired volume as well as the inspired and alveolar gas concentrations. To verify equipment performance over its specified range of operation, it requires multiple precision alveolar gas mixtures with different concentrations of CO and tracer gases. 
     Because the Hans Rudolph does not control the breath hold time, the breath hold time reported by the D LCO  device under test is required to confirm the exact target value. Hans Rudolph provides software for the calculation of the exact target value (based on Eq (1)) after the test is performed. 
     For trouble-shooting, ATS-ERS (MacIntyre N. et. al. Standardization of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005; 26: 720-735) also recommends the following:
         1. Leak testing if it is appropriate to the device under test   2. A D LCO  test with a calibrated 3.0-L syringe should be used, which is performed by attaching the syringe to the instrument in the test mode. Test gas is withdrawn from the D LCO  machine by the syringe and then reinserted at the end of the breath-hold. The measured D LCO  should be near zero and the measured VI should be ≈3.3 L (3.0 L×the body temperature, ambient pressure, saturated with water vapor (BTPS) factor). This procedure checks the inhaled volume accuracy in the D LCO  test mode, which may be in error when spirometry measurements are not.       

     The simulator identified in the ATS-ERS D LCO  testing guideline (MacIntyre N. et. al. Standardization of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005; 26: 720-735) was developed by Glissmeyer, et. al. (Glissmeyer E W, Jensen R L, Crapo R O, Greenway L W. Initial Testing with a carbon monoxide diffusing capacity simulator. J Invest Med 1999; 47: 37A) and manufactured by Hans Rudolph, Inc, Kansas City, Mo. 
     Current D LCO  testing devices and practices suffer from several deficiencies and disadvantages. The trouble-shooting methodology suggested by ATS-ERS (using a 3 liter syringe) does not affirm the D LCO  measurement accuracy of a D LCO  device over its intended range of operation. At best, this test establishes the accuracy of flow/volume measurement component of the D LCO  device. It may also demonstrate that the CO and tracer gas detectors have similar response (but not necessarily accurate or linear) over a narrow range of gas concentrations. 
     The use of the Hans Rudolph simulator for quality control of D LCO  measurements has been well documented (Jensen R, et. al. Quality control of D LCO  instruments in global clinical trials. Eur Respir J 2009; 33: 1-7. Jensen R L, et. al. Instrument Accuracy and Reproducibility in Measurements of Pulmonary Function. Chest 2007; 132: 388-395.). 
     There are a number of challenges and disadvantages in using the Hans Rudolph simulator. First, the procedure is complex and prone to errors. The 3-liter syringe used to simulate exhalation must be filled with precisely known concentration of alveolar gas prior to each test. The syringe must be adequately purged prior to filling. Difficulties arise from a significant certainty that the syringe is properly purged of any previously used gas mixtures. Moreover, during the testing process, the 3-way valve must be turned immediately before the emptying of the 3-liter syringe begins to ensure any chance that the test is accurate. If precise timing of the operation of the 3-liter syringe is not maintained the test of the D LCO  equipment is invalid and the test must be re-performed, resulting in increased costs for the precise gas mixtures used in the testing or even improper calibration of the D LCO  equipment based on faulty test results. 
     Second, target D LCO  value changes with every test and every new gas cylinder. To ensure that D LCO  device operates correctly throughout its intended range of operation, it must be tested at various combinations of CO and tracer gas concentrations, thereby requiring a number of precision (typically 1% or better) pre-mixed gases. Switching alveolar gas bottles adds to the complexity and cumbersomeness of simulator testing. 
     Third, precision gases are expensive. Delivery and shipment of the precision gases are difficult as these gases are typically classified as medical gases by many countries. One purpose of D LCO  equipment is to perform clinical studies or trials in remote locations. For studies and trials to have statistically valid results, the D LCO  equipment, which may be in multiple remote locations, must be properly calibrated. This calibration of multiple, remote D LCO  equipment simulators is complex in and of itself and even more so with the added cost and complexity of shipping the required medical gases used in the testing. 
     Fourth, the current D LCO  simulators, even though a fraction of the cost of the D LCO  device, is relatively expensive. Current simulators require their own test gas which can be costly 
     Fifth, current simulators are bulky, which also adds to their cost. They require two syringes along with precision test gases. As discussed above, shipping and other costs for current simulators are high not only because of the required precision gases, but costs can increase for storage of the simulator and the gases it requires. All of these costs are exacerbated considering that many times D LCO  equipment is used in remote and often poor locations and for non-profit endeavors, such as clinical studies or trials. 
     Although present devices are functional, they are not sufficiently accurate or otherwise satisfactory. Accordingly, a system and method are needed to address the shortfalls of present technology and to provide other new and innovative features. 
     SUMMARY OF THE INVENTION 
     Exemplary embodiments of the present invention that are shown in the drawings are summarized below. These and other embodiments are more fully described in the Detailed Description section. It is to be understood, however, that there is no intention to limit the invention to the forms described in this Summary of the Invention or in the Detailed Description. One skilled in the art can recognize that there are numerous modifications, equivalents and alternative constructions that fall within the spirit and scope of the invention as expressed in the claims. 
     The present invention can provide a system and method for D LCO  quality control testing. In one exemplary embodiment, the present invention can include a method for testing a pulmonary diagnostic device comprising: accepting a first configured predetermined maximum volume of a space; receiving atmospheric gas into the space; receiving a predetermined volume of a first D LCO  test gas from the pulmonary diagnostic device into the space, the first configured predetermined maximum volume being larger than the predetermined volume of the first D LCO  test gas, the first D LCO  test gas comprising carbon monoxide and a tracer gas; diluting concentrations of the carbon monoxide and the tracer gas in the first D LCO  test gas with the atmospheric gas in the space resulting in a first diluted D LCO  test gas mixture; expelling from the space the first diluted D LCO  test gas mixture into the pulmonary diagnostic device; and confirming that the pulmonary diagnostic device reports an inspired volume consistent with the predetermined volume of first D LCO  test gas, an alveolar volume consistent with the first maximum predetermined volume of the space, and a D LCO  value consistent with zero diffusion. 
     In another exemplary embodiment, the present invention can include an apparatus for testing a pulmonary diagnostic device capable of performing single breath carbon monoxide uptake measurement, comprising: a single gas-tight chamber, with a gas port configured to receive gas from or to expel gas to the exterior of the chamber and a partition configured to change the volume of the single gas-tight chamber; the single gas-tight chamber capable of expanding and contracting; a member disposed within the single gas-tight chamber and configured to limit the movement of the partition, the member being adjustable to set a predetermined maximum volume of the single gas-tight chamber and a predetermined volume of D LCO  test gas that the single gas-tight chamber can receive; and an interface configured for the transfer of gas between the pulmonary diagnostic device and the simulation device via the gas port. 
     A D LCO  instrument will report accurate D LCO  values if it measures inspired volume accurately and its CO and tracer gas analyzers are linear, i.e. the analyzer outputs are directly proportional to the gas concentrations. Absolute accuracy for the gas analyzers is not required. The present invention provides a method and system for confirming accurate measurement. 
     D LCO  testing provides a measure for how well the lungs exchange gases with the blood across the alveolar capillary membrane. The single-breath determination of D LCO  involves the following maneuver for the subject:
         Tidal breathing, once the mouthpiece and nose clip are in place   Unforced exhalation to residual volume (RV)   Rapid inhalation (in less than 4 seconds) of the D LCO  test gas to total lung capacity (TLC) with the inspired volume (V I ) as close to the know vital capacity (VC) as possible (greater than 85% VC).   Breath hold for 10+/−2 seconds   Smooth and unforced expiration exhalation in less than 4 seconds       

     The test gas is made up of primarily air with a small amount of CO (typically 0.3%) and a small amount of inert gas (typically helium or methane). CO has a very high affinity to the hemoglobin and is readily carried away by the blood as soon as it crosses the alveolar capillary membrane. The inert gas (also called tracer gas) is chosen for its low solubility in blood and affinity to hemoglobin. Once the test gas is inspired, the CO and tracer gas concentrations are diluted by the air in the lung prior to the inhalation. CO concentration is further reduced during the breath hold time as it diffuses into the blood. 
     The D LCO  equipment records and measures the following:
         Flow/volume time trace of the maneuver   CO and tracer gas concentration time traces throughout the maneuver
 
(MacIntyre N. et. al. Standardization of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005; 26: 720-73)
       

     From the recorded time traces (data), the CO and tracer gas concentrations in the inhaled and exhaled gas samples are determined. The equipment calculates D LCO  according to the following equation: 
                           ⁢       D   LCO     =         ×     (     -     )         ⁢     ln   ⁡     (         F     I   ,   CO       ⁢   ⁢     /     ⁢   ⁢     F     A   ,   CO             F     I   ,   Tr       ⁢   ⁢     /     ⁢   ⁢     F     A   ,   Tr           )                   Eq   ⁢           ⁢     (   1   )                         ⁢       V   A     =       (       V   I     -     V   D       )     ×     (       ⁢       F     I   ,   Tr       /     F     A   ,   Tr             )                 Eq   ⁢           ⁢     (   2   )                 
Where:
 
     V A  is the alveolar volume, expressed in mL STPD 
     V D  is the sum of the instrument dead space and subject&#39;s anatomic dead space 
     P B  is the barometric pressure and P B     2     0  the water vapor pressure in the lung 
     F I,CO , F A,CO , F I,Tr , and F A,Tr  are concentrations of inhaled CO, alveolar CO, inhaled tracer, and alveolar tracer gases respectively 
     The D LCO  equipment captures the following parameters: V I , F I,CO , F A,CO , F I,Tr , and F A,Tr . Both F I,CO  and F I,Tr  represent the concentrations of CO and tracer gas in the test gas. Typical CO and tracer gas concentrations employed by most equipment manufacturer is 3000 ppm (or 0.3%). 
     Inspired Volume (V I ): 
     V I  is similar to vital capacity (VC) in magnitude and therefore should have a typical value ranging from around 1.5 liters (for a child) to over 6 liters (for an adult). (Hankinson, J L, Odencrantz J R, Fedan K B. Spirometric Reference Values from a Sample of the General U.S. Population Am J Respir Crit Care Med 1999; 159:179-187) 
     Tracer Gas Concentrations: 
     To estimate the range of F A,Tr , one notes that: 
     
       
         
           
             
               
                 
                   
                       
                   
                   ⁢ 
                   
                     
                       = 
                       
                         
               
                         × 
                       
                     
                     ⁢ 
                     
                       
 
                     
                     ⁢ 
                     
                         
                     
                     ⁢ 
                     and 
                   
                 
               
               
                 
                   Eq 
                   ⁢ 
                   
                       
                   
                   ⁢ 
                   
                     ( 
                     
                       3 
                       ⁢ 
                       a 
                     
                     ) 
                   
                 
               
             
             
               
                 
                   
                       
                   
                   ⁢ 
                   
                     
                       
                         
                           ( 
                           
                             - 
                           
                           ) 
                         
                       
                       ≈ 
                       
             
                       ≈ 
                       
             
                     
                     = 
                     
                       1 
                       - 
                       
                         RV 
                         TLC 
                       
                     
                   
                 
               
               
                 
                   Eq 
                   ⁢ 
                   
                       
                   
                   ⁢ 
                   
                     ( 
                     
                       3 
                       ⁢ 
                       b 
                     
                     ) 
                   
                 
               
             
           
         
       
     
     For most subjects, the RV to TLC ratio will be between 20% and 50% (Needham C D, Rogan M C, and McDonald I. Normal Standards for Lung Volumes, Intrapulmonary Gas-Mixing, and Maximum Breathing Capacity. Thorax 1954; 9:313-325.) As a result, F A,Tr  will be 50% to 80% of F I,Tr  and the tracer gas analyzer must have a linear response between 50% and 100% of tracer gas concentration found in the D LCO  test gas. 
     CO Concentrations: 
     Due to diffusion across the alveolar-capillary membrane, the ratio of alveolar CO concentration to inhaled CO concentration is lower than the corresponding ratio for the tracer gas. The effect of diffusion on alveolar CO concentration can be estimated from the D LCO  predicted equation provided by Crapo, et. al. (Crapo R O, Morris A H, Clayton P D, and Nixon C R. Lung Volumes in Healthy Nonsmoking Adults. Bull. Europ. Physiopathol. Respir. 1982; 18:419-425):
 
Men:  D   LCO =1.0566*Height(inches)−0.2190*Age(years)−26.34
 
Women:  D   LCO =0.6502*Height(inches)−0.1440*Age(years)−8.36
 
     The low limit of alveolar CO concentration will be associated with subjects with high D LCO  values. To this end, we consider a 21-year-old male with a height of 78 inches (approximately 2 meters). Using the above-predicted equation, Eq (2), this subject will have a D LCO  of 51.48. 
     Using the predicted normal equations from Crapo, this individual will likely have an alveolar volume, V A (≈TLC) of 8.35 liters and VC of 6.79 liters at BTPS condition. This translates into a V A  of 6.9 liters at STPD condition. 
     Substituting 51.48 ml/min/mm of Hg for D LCO , 6900 mL for V A , 10 seconds for t, 760 mm of Hg for P B , and 47 mm of Hg for P H     2     0  in Eq(1), we obtain: 
     
       
         
           
             
               
                 
                   
                       
                   
                   ⁢ 
                   
                     
                       
                         ln 
                         ⁢ 
                         
                             
                         
                         ⁢ 
                         
                           ( 
                           
                             
                               ⁢ 
                               
                                 / 
                               
                               ⁢ 
                             
                             
                               ⁢ 
                               
                                 / 
                               
                               ⁢ 
                             
                           
                           ) 
                         
                       
                       = 
                       
                         
                           
                             × 
                             
                               ( 
                               
                                 10 
                                 60 
                               
                               ) 
                             
                             × 
                             
                               ( 
                               
                                 - 
                               
                               ) 
                             
                           
                         
                         = 
                         0.8866 
                       
                     
                     ⁢ 
                     
                       
 
                     
                     ⁢ 
                     
                         
                     
                     ⁢ 
                     or 
                   
                 
               
               
                 
                   Eq 
                   ⁢ 
                   
                       
                   
                   ⁢ 
                   
                     ( 
                     4 
                     ) 
                   
                 
               
             
             
               
                 
                   
                       
                   
                   ⁢ 
                   
                     
                       
                         
                           ⁢ 
                           
                             / 
                           
                           ⁢ 
                         
                         
                           ⁢ 
                           
                             / 
                           
                           ⁢ 
                         
                       
                       = 
                       2.43 
                     
                     ⁢ 
                     
                       
 
                     
                     ⁢ 
                     
                         
                     
                     ⁢ 
                     
                       
             
                       = 
                       
                         
               
                         × 
                         
               
                       
                     
                   
                 
               
               
                 
                   Eq 
                   ⁢ 
                   
                       
                   
                   ⁢ 
                   
                     ( 
                     5 
                     ) 
                   
                 
               
             
           
         
       
     
     A high D LCO  and therefore healthy subject will likely have a RV/TLC approaches the lower end of the range (20% to 50%). As a result, this subject will have (from Eq (3a) and Eq (3b)) a 
                     ⁢   
           
ratio of 0.8 and (from Eq (5)) a
 
                     ⁢   
           
ratio of approximately 0.3. The CO gas analyzer must demonstrate a linear response between 30% and 100% of the CO gas concentration found in the D LCO  test gas.
 
     For quality control of D LCO  equipment, ATS-ERS (MacIntyre N. et. al. Standardization of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005; 26: 720-735) recommends performing the following: 
     1. Gas-analyzer zeroing: before/after each test 
     2. Volume (flow-sensor) accuracy: daily 
     3. Standard subject or simulator testing: at least weekly 
     4. Gas analyzer linearity: every 3 months 
     5. Timer accuracy: every 3 months 
     As previously stated, the above-described embodiments and implementations are for illustration purposes only. Numerous other embodiments, implementations, and details of the invention are easily recognized by those of skill in the art from the following descriptions and claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Various objects and advantages and a more complete understanding of the present invention are apparent and more readily appreciated by reference to the following Detailed Description and to the appended claims when taken in conjunction with the accompanying Drawings wherein: 
         FIG. 1  illustrates an embodiment of a D LCO  simulator. 
         FIG. 2  illustrates an embodiment of a D LCO  simulator 
         FIG. 3  illustrates a portion of an embodiment of a system that includes a D LCO  testing device and a D LCO  simulator. 
         FIG. 4  illustrates a view of a D LCO  simulator. 
         FIGS. 5-8  illustrate views of an end cap of a D LCO  simulator. 
         FIGS. 9-10  are flowcharts of method for quality control of D LCO  equipment. 
     
    
    
     DETAILED DESCRIPTION 
     Referring now to the drawings, where like or similar elements are designated with identical reference numerals throughout the several views, and referring in particular to  FIG. 1 , it illustrates the cross-section of an embodiment of a single-syringe simulator quality control device  100 . The simulator syringe  100  has an inactive space  110  and a stroke volume  120  and can be a curvilinear or non-curvilinear cylinder. In a preferred embodiment, the maximum stroke volume is 6 liters or greater. Such a volume is most beneficial to simulate the inspired volumes associated with large adults. The volume of the inactive space  110  can be adjusted by moving the piston  130  either forward or back. The volume of the inactive space  110  starts from a predetermined volume. In other words, the piston  130  starts from a predetermined position. The predetermined volume can be set by a collar  150  situated on the shaft  140  of the piston  130  outside the body of the simulator syringe  100 . In some embodiments, the collar  150  is adjustable so that the predetermined volume is likewise adjustable. The minimum range of adjustment of the inactive space  110  is from 20% to 70% of the total volume. Such a volume range produces alveolar gas concentrations ranging from 80% to 30% of the CO and tracer gas concentrations in the D LCO  test gas. By adjusting the volume of the inactive space, the stroke volume is likewise adjusted. In this way, the simulated maximum predetermined volume is adjustable. Vent holes  170  ensure that the piston  130  can move freely throughout the stroke volume  120  by maintaining the pressure behind the piston close to that of the ambient condition. 
     The piston  130  can have different thicknesses and can be composed of different materials. In some embodiments, the piston  130  can make full contact with the inner wall of the simulator syringe  100  such as to create a hermetic seal between the inactive space  110  and the stroke volume  120 . 
     Referring now to  FIG. 2 , an illustration of a simulator with a cut-away view of a simulator syringe  200  is shown. In the embodiment shown, adjustable stop  215  is external to the simulator syringe and adjustable stop  216  is disposed in the interior of the simulator syringe  200 . Placement of the stop  215  can be adjusted to determine the starting volume of the inactive space whereas the placement of the stop  216  can be adjusted to determine the maximum volume of the inactive space. In a preferred embodiment, the stop  215  and stop  216  are adjustable so that the starting volume of the inactive space  205  and the maximum volume of the inactive space  205  can be determined by placement of the stop  215  and stop  216 . The adjustable stop  215  can be adjusted from outside the body of the simulator syringe  200 . Similarly, the adjustable stop  216  can be adjusted by removing the positioning cap  260  by first loosening up the locking screw  262 . In other embodiments, a stop can be situated either internal, external, or both to the body of the simulator syringe  200  can be used to determine the starting and maximum volumes of the inactive space  205 . 
     The simulator syringe  200  also includes an end cap  225 . Within the end cap  225  is a fan for priming the inactive space  205  with atmospheric air. A battery pack  250  is used to power the fan. In other embodiments, the fan can be powered by some other DC or AC power source or can be manually powered. End caps similar to end cap  225  are discussed in more detail below. Attached to the end cap  225  is valve  230  with valve handle  235 . Valve  230  can be used to isolate the simulator syringe  200  and the inactive space  205  from the D LCO  equipment. This can be useful to simulate a breath hold during a test. It should be understood that other embodiments will lack a valve  230 . 
     Attached to exhaust tube  240  is the mouth-piece end  245  (i.e., gas port). In some embodiments, the end  245  of the simulator can be a shaped end that fits onto a mouthpiece of the D LCO  equipment to be tested or calibrated. Such shaped ends can be customized based on the particular D LCO  equipment. In other embodiments, the end  245  can be a normal end of the syringe, the end  245  not intended to fit snuggly onto or into the mouthpiece or mask of the D LCO  equipment. In yet other embodiments, the end  245  can include an end cap as illustrated in  FIGS. 4-8  and discussed below. It is to be understood that the configuration of components attached to end cap  245  is not meant to be limiting. Other embodiments can include a subset of these components, additional components, and different configurations of components. The combined volume of those portions of the simulator device between the syringe volume of the diagnostic device represent the analog of the anatomical dead space (i.e., mouth, trachea, etc.) of a patient/subject. 
     Referring now to  FIG. 3 , an embodiment of at least part of a system of D LCO  equipment  300  and a simulator  100  is shown. In the embodiment shown, the simulator  100  has a generic end  160  (i.e., gas port) for communicating with the D LCO  equipment  300  and its mouthpiece  310 . As discussed above, the simulator syringe  100  can have a custom end to fit the particular D LCO  equipment  300  or and end cap. It should be understood that D LCO  simulators in accordance with the present invention can be used with different types of D LCO  equipment and that the invention is not limited to any particular type of D LCO  equipment. 
       FIG. 4  shows an embodiment of a simulator syringe  410  that includes an end cap  420 . The simulator syringe  410  also includes a plunger  450  for the piston internal to the simulator syringe  410 . The end cap  420  shown serves as a manifold to connect the simulator syringe  410  to a D LCO  equipment connector, which is not shown. The D LCO  equipment connector enables communication between the simulator and the D LCO  equipment and is similar to the end  225  described above. The hole  430  of the end cap  420  receives the D LCO  equipment connector. In the embodiment shown, the grooves  440  allow access to fasteners used to attach end cap  420  to the simulator syringe  410 . 
     Referring now to  FIG. 5 , a schematic of the end cap  420  is shown. The cavity  530  can be used to house a fan or blower to promote gas mixing in the inactive space  110 ,  205 . Cavity  540  can be used to house a plate with exhaust for the fan or blower. Those of skill in the art can appreciate other arrangements for a fan or blower and an exhaust. For example, in other embodiments, a fan can be placed directly on the body of the simulator syringe. The connector hole  430  allows for the D LCO  equipment connector to communicate with the simulator syringe. Cavity  520  can include threading to screw the end cap  420  onto the body of the simulator syringe. 
       FIG. 6  includes a side view of the end cap  420  as described above and shown in  FIG. 5 . In  FIG. 7 , a three-quarter view of the end cap  420  as described above and shown in  FIGS. 5-6  is shown. In  FIG. 8 , the front view of the end cap  420  as described above and shown in  FIGS. 5-7  is shown. The illustration of end cap  420  of  FIG. 8  includes a cover  810  over the cavities ( 520 ,  530 ,  540 ) as shown in  FIGS. 5 and 7 . 
     Referring now to  FIG. 9  is a flowchart depicting a method  900  for testing D LCO  equipment. At step  910 , a predetermined maximum volume of space is configured. In a preferred embodiment, a collar is set at a point along a longitudinal axis of the syringe cylinder so that the syringe piston cannot move beyond the collar during the simulation of inspiration. In other embodiments, a maximum volume can be configured by setting a some other rigid portion of the simulator device at which a wall or boundary of the space cannot be moved past. Such a rigid portion can include an adjustable external wall or wall portion that the boundary of the space expands to. At step  920 , atmospheric gas is received in the space. At this step  920 , the simulator is primed so that an initial inactive space within the simulator contains atmospheric gases that would also be present in the lungs of a patient using the D LCO  equipment. In a preferred embodiment, priming the simulator so that atmospheric gas is properly received can be accomplished by a piston moving in a reciprocating motion, by creating a vacuum or partial vacuum within the space, by mechanically introducing atmospheric gas by a fan or blower, and the like. 
     At step  930 , a predetermined volume of a D LCO  test gas is received. In a preferred embodiment, the D LCO  test gas contains at least carbon monoxide and a tracer gas and will be received from the diagnostic device. In such a case, the same test gas cartridge or other container that is typically used during an actual diagnosis with a patient or subject is also used for the simulation. Further, in a preferred embodiment using a syringe, the volume in the syringe is increased to the predetermined maximum volume. 
     In some embodiments, a piston is pulled back to a predefined stop location. In other embodiments, other mechanisms for expanding the volume to a predetermined volume can be used. For example, the volumes in other embodiments can be other types of curvilinear volumes, for example spheroid, elliptical cylinder, conical cylinder, cone, etc., or non-curvilinear volumes, for example a cube with one or more expanding sides. In yet other embodiments, volume can be expanded by virtue of some elasticity in one or more facets of the simulator. The elasticity can be limited or have predefined extents. Accordingly, other sides of the volume can be expanded out to increase the volume. In preferred embodiments, the total volume of the simulator is constant and known. In embodiments in which a syringe or other type of dual-chamber configuration is used, the total volume of the inactive space and stroke volume is constant and known. Further, in a preferred embodiment, receiving the test gas should simulate exhalation in a diagnostic setting and last 4 seconds or less. 
     During an actual test of a patient or subject, at the end of a maximal inhalation, the gas volume in the lung is the total lung capacity, or alveolar volume. In a preferred embodiment, when the piston is pulled all the way back or the volume of the space otherwise reaches the predetermined maximum, the gas volume inside the space is the sum of the volume corresponding to piston displacement or the volume increase of the space (analogous to the inspired volume in the case of a patient/subject) and the volume of the inactive space (analogous to the residual volume in the patient/human). Therefore, a simulator will always have the same “Total Lung Capacity or Alveolar Volume” regardless of the initial inactive space. 
     At step  940 , the concentrations of carbon monoxide and the tracer gas from the test gas are diluted. Here, those concentrations can mix with the atmospheric gas to create a test gas concentration. In some embodiments, the dilution can be accomplished or assisted by way of convection or diffusion. For example, the gases in the space can be exposed to a fan that provide convective flow within the space, thereby causing the gases to mix and the test gas concentrations to become diluted and more uniform throughout the interior of the syringe volume. In another embodiment, vanes at or near the inlet port of the syringe can redirect the flow of the gas as the syringe piston is pulled back thereby causing gas swirls within the interior of the syringe and resulting in enhanced mixing of the test gas and the atmospheric gas. While in other embodiments, diffusing the gas concentrations can be accomplished by pausing for a predetermined amount of time before expelling the test gas mixture, thus allowing the test gas concentrations to naturally diffuse. The predetermined time is optimally at least 10 seconds. At step  950 , the D LCO  test gas mixture is expelled. In a preferred embodiment, the expulsion is accomplished by decreasing the volume of the space. The D LCO  test gas mixture is expelled to the pulmonary diagnostic equipment for testing. In a preferred embodiment, the expulsion should simulate exhalation and last 4 seconds or less. 
     During an actual test of a patient or subject, at the end of a maximal exhalation, the gas volume in the lung is the residual volume. In a preferred embodiment, when the test gas is expelled, via pushing the piston all the way in or by otherwise reducing the volume of the space, the gas volume left inside the syringe is the inactive space. 
     At step  960 , measurements from the pulmonary diagnostic device are confirmed. In a preferred embodiment, the method is designed to produce the following results for a properly functioning D LCO  device, regardless of the predetermined maximum volume:
         Measured alveolar volume equal to the predetermined maximum volume, within the error specifications of the pulmonary diagnostic D LCO  device and reported under the same conditions (e.g. BTPS or STPD)   Measured D LCO  value of zero, within the error specifications of the pulmonary diagnostic D LCO  device       

     The relationship between alveolar volume, inspired volume, dead space volume, inspired tracer gas concentration and alveolar tracer gas concentration is provided by: 
     
       
         
           
             
                 
             
             ⁢ 
             
               
                 V 
                 A 
               
               = 
               
                 
                   ( 
                   
                     
                       V 
                       I 
                     
                     - 
                     
                       V 
                       D 
                     
                   
                   ) 
                 
                 × 
                 
                   ( 
                   
         
                   ) 
                 
               
             
           
         
       
     
     When D LCO  testing is performed on a patient, V D  is the sum of the D LCO  equipment patient interface dead space and the patient&#39;s anatomical dead space (generally equal to 2.2 mL per kg of patient&#39;s weight). When testing is performed with the syringe simulator, the volume of the coupling between the D LCO  equipment patient interface and the syringe will replace the anatomical dead space. 
     As the inactive space increases (by varying the collar position on the shaft of the syringe), both the inspired volume and F A,Tr  decrease and in such a manner that the reported alveolar volume remains constant, if the tracer gas analyzer is linear throughout its intended range of operation. Errors in the alveolar volume (i.e. deviation from the expected value) are a good representation of the linearization error of the tracer gas analyzer. 
     Since CO is diluted in exactly the way as the tracer gas by the gas in the inactive volume, the ratios F I,CO /F A,CO  and F I,Tr /F A,Tr  should be identical. As a result, 
                           ⁢       ln   ⁢           ⁢     (       ⁢     /     ⁢       ⁢     /     ⁢       )       =       ln   ⁡     (   1   )       =   0               (     Eq   ⁢           ⁢     (   2   )       )               
and according to Eq (1) the reported D LCO  values should remain near 0 as the inactive space increases and alveolar CO and tracer gas concentrations decrease. Slight deviations from 0 are a good representation of overall accuracy of the D LCO  equipment.
 
     It is important to note that D LCO  values will be zero if the ratios F I,CO /F A,CO  and F I,Tr /F A,Tr  are identical. The two values are identical when both analyzers have similar/identical response characteristics to concentrations. However, zero D LCO  values during testing of the equipment with a syringe alone do not guarantee that the gas (CO and tracer) analyzers are linear, as recommended by ATS/ERS. 
     The combination of constant alveolar volume and zero D LCO  values ensures: (1) the tracer gas analyzer is linear and (2) the CO gas and tracer gas analyzers have identical linearity characteristics. Hence, the CO gas analyzer must also be linear. 
     To properly verify its performance, D LCO  equipment should be tested at different combinations of inspired volumes, CO gas concentrations, and tracer gas concentrations corresponding to conditions encountered in subject testing. 
     With the collar set on the 1 liter mark, the inspire volume (V I ) should be 6 liters (ATPD)+/−3% or better, when a 7 liter simulator syringe is employed. Note: the D LCO  device may report V I  at BTPS. Appropriate conversion must be performed prior to comparison with the expected values. Similarly with the collar set on 2, 3, 4, and 5 liter marks, the V I  should be 5, 4, 3, and 2 liters respectively. The alveolar volume (V A ) should be within 5% or better of the total internal volume of the simulator (syringe) for a D LCO  equipment in reasonable condition. Note: the D LCO  device may report V A  at BTPS or STPD. Appropriate conversion must be performed prior to comparison with the expected value. The D LCO  values should be less than 2 mL/min/mm of Hg. The simulator should be checked for leak as well if D LCO  values are higher than expected for all collar positions. 
     Referring now to  FIG. 10 , a flowchart for a method  1000  in accordance with the present invention is shown. At step  1010 , a configured predetermined maximum volume of a syringe is accepted. In a preferred embodiment, a collar is adjusted so that a piston in the syringe is stopped at a point where a particular maximum volume is reached. In one embodiment, an optimal maximum volume is at least 1 liter and no more than 7 liters. At step  1020 , the piston of the syringe is reciprocated. In a preferred embodiment, reciprocation of the piston is accomplished via a plunger and the result is the syringe becomes filled with the ambient air. 
     At step  1030 , the syringe is connected to a D LCO  diagnostic device. In a preferred embodiment, the syringe includes an end cap that attaches to the mouthpiece or other patient interface of the D LCO  diagnostic device. At step  1040 , the piston is reciprocated again. Reciprocation of the piston simulates tidal breathing of a patient/subject. In a preferred embodiment, the piston is reciprocated so that each reciprocation displaces between 0.5 liters and 1 liter, in the simulation of maximal exhalation, the piston is pushed all the way in, and in the simulation of maximal inhalation, the piston is pulled out rapidly. As a result of the maximal inhalation, test gas from the D LCO  diagnostic device is received by the syringe. 
     At step  1050 , the syringe is disengaged from the D LCO  diagnostic device. In a preferred embodiment, a valve can be closed to separate the syringe space from the D LCO  diagnostic device and the syringe is disengaged for approximately 10 seconds. At step  1060 , the syringe is reengaged with the D LCO  diagnostic device. In a preferred embodiment, a valve can be opened to remove a separation between the syringe space and the D LCO  diagnostic device. In other embodiments, steps  1030  and  1050  can be accomplished by removing the simulator syringe from the D LCO  diagnostic device to actuate a member that seals the end of the simulator syringe. Those of skill in the art can appreciate that the disengagement can be accomplished by other mechanisms. 
     At step  1060 , the syringe is reengaged with the D LCO  diagnostic device. At step  1070 , the piston is reciprocated. In preferred embodiment, the piston is pushed in to expel test gas from the simulator syringe to the D LCO  diagnostic device for measurement. At step  1080 , a second configured predetermined maximum volume of the syringe is accepted. In a preferred embodiment, the second configured predetermined maximum volume is different that the configured predetermined maximum volume at step  1010 . And the second configured predetermined maximum volume can be set in accordance with embodiments described herein. In a preferred embodiment steps  1020  through  1070  are repeated. In this way, the accuracy of the D LCO  diagnostic device&#39;s measurements can be verified. In a preferred embodiment, the steps are repeated with configured predetermined volumes set so that the inactive space of the simulator syringe ranges from 1 to 5 liters at 1 liter intervals. 
     In conclusion, the present invention provides, among other things, a system and method for the quality control of D LCO  equipment. Those skilled in the art can readily recognize that numerous variations and substitutions may be made in the invention, its use and its configuration to achieve substantially the same results as achieved by the embodiments described herein. Accordingly, there is no intention to limit the invention to the disclosed exemplary forms. Many variations, modifications and alternative constructions fall within the scope and spirit of the disclosed invention as expressed in the claims.