Effects of posture and bronchoconstriction on low-frequency input and transfer impedances in humans

We simultaneously evaluated the mechanical response of the total respiratory system, lung, and chest wall to changes in posture and to bronchoconstriction. We synthesized the optimal ventilation waveform (OVW) approach, which simultaneously provides ventilation and multifrequency forcing, with optoelectronic plethysmography (OEP) to measure chest wall flow globally and locally. We applied an OVW containing six frequencies from 0.156 to 4.6 Hz to the mouth of six healthy men in the seated and supine positions, before and after methacholine challenge. We measured mouth, esophageal, and transpulmonary pressures, airway flow by pneumotachometry, and total chest wall, pulmonary rib cage, and abdominal volumes by OEP. We computed total respiratory, lung, and chest wall input impedances and the total and regional transfer impedances (Ztr). These data were appropriately sensitive to changes in posture, showing added resistance in supine vs. seated position. The Ztr were also highly sensitive to lung constriction, more so than input impedance, as the former is minimally distorted by shunting of flow into alveolar gas compression and airway walls. Local impedances show that, during bronchoconstriction and at typical breathing frequencies, the contribution of the abdomen becomes amplified relative to the rib cage. A similar redistribution occurs when passing from seated to supine. These data suggest that the OEP-OVW approach for measuring Ztr could noninvasively track important lung and respiratory conditions, even in subjects who cannot cooperate. Applications might range from routine evaluation of airway hyperreactivity in asthmatic subjects to critical conditions in the supine position during mechanical ventilation.

Tissue heterogeneity in the mouse lung: effects of elastase treatment

We developed a network model in an attempt to characterize heterogeneity of tissue elasticity of the lung. The model includes a parallel set of pathways, each consisting of an airway resistance, an airway inertance, and a tissue element connected in series. The airway resistance, airway inertance, and the hysteresivity of the tissue elements were the same in each pathway, whereas the tissue elastance (H) followed a hyperbolic distribution between a minimum and maximum. To test the model, we measured the input impedance of the respiratory system of ventilated normal and emphysematous C57BL/6 mice in closed chest condition at four levels of positive end-expiratory pressures. Mild emphysema was developed by nebulized porcine pancreatic elastase (PPE) (30 IU/day × 6 days). Respiratory mechanics were studied 3 wk following the initial treatment. The model significantly improved the fitting error compared with a single-compartment model. The PPE treatment was associated with an increase in mean alveolar diameter and a decrease in minimum, maximum, and mean H. The coefficient of variation of H was significantly larger in emphysema (40%) than that in control (32%). These results indicate that PPE treatment resulted in increased time-constant inequalities associated with a wider distribution of H. The heterogeneity of alveolar size (diameters and area) was also larger in emphysema, suggesting that the model-based tissue elastance heterogeneity may reflect the underlying heterogeneity of the alveolar structure.

Servo-Controlled Pneumatic Pressure Oscillator for Respiratory Impedance Measurements and High-Frequency Ventilation

The ability to provide forced oscillatory excitation of the respiratory system can be useful in mechanical impedance measurements as well as high frequency ventilation (HFV). Experimental systems currently used for generating forced oscillations are limited in their ability to provide high amplitude flows or maintain the respiratory system at a constant mean pressure during excitation. This paper presents the design and implementation of a pneumatic pressure oscillator based on a proportional solenoid valve. The device is capable of providing forced oscillatory excitations to the respiratory system over a bandwidth suitable for mechanical impedance measurements and HVF. It delivers high amplitude flows (> 1.4 l/s) and utilizes a servo-control mechanism to maintain a load at a fixed mean pressure during simultaneous oscillation. Under open-loop conditions, the device exhibited a static hysteresis of approximately 7%, while its dynamic magnitude and phase responses were flat out to 10 Hz. Broad-band measurement of total harmonic distortion was approximately 19%. Under closed-loop conditions, the oscillator was able to maintain a mechanical test load at both positive and negative mean pressures during oscillatory excitations from 0.1 to 10.0 Hz. Impedance of the test load agreed closely with theoretical predictions. We conclude that this servo-controlled oscillator can be a useful tool for respiratory impedance measurements as well as HFV.

Relating maximum airway dilation and subsequent reconstriction to reactivity in human lungs

Measures of airway resistance (Raw) during deep inspiration (DI) suggest that asthmatic subjects possess stiffer, more reactive airway smooth muscle. There is evidence that one can enhance airway reactivity in healthy lungs by prohibiting DI for an extended period. The present study had two goals. First, we determined whether the maximum dilation capacity of asthmatic subjects depended on the rate of the DI. Second, we investigated whether the enhanced reactivity in healthy humans might derive from additional mechanisms not present in asthmatic subjects. For the first goal, we tracked Raw in seven healthy and seven asthmatic subjects during a noncoached DI, a DI with a 5- to 10-s breath hold at total lung capacity, and a rapid DI. We found that the minimum resistance achieved at total lung capacity was independent of the manner in which the DI was performed. For the second goal, we tracked the rate of return of Raw after a DI as well as dynamic lung elastance before and after the DI, at baseline and after bronchial challenge. A drop in lung elastance post-DI would indicate reopening of lung regions and/or reduced heterogeneities. The data show that constricted healthy but not asthmatic subjects produce longer lasting residual dilation. Hence, a portion of the enhanced reactivity in a healthy subject's response to prohibition of DIs is likely due to airway closure and/or atelectasis that can be ablated with a DI. We conclude that preventing DIs does not ensure that healthy subjects will transition entirely to an asthmatic-like hyperreactive lung state.

Lung and alveolar wall elastic and hysteretic behavior in rats: effects of in vivo elastase treatment

We investigated the relationship between the microscopic elastic and hysteretic behavior of the alveolar walls and the macroscopic mechanical properties of the whole lung in an in vivo elastase-treated rat model of emphysema. We measured the input impedance of isolated lungs at three levels of transpulmonary pressure (Ptp) and used a linear model to estimate the dynamic elastance and hysteresivity of the lungs. The elastance of the normal lungs increased steeply with Ptp, whereas this dependence diminished in the treated lungs. Hysteresivity decreased significantly with Ptp in the normal lungs, but this dependence disappeared in the treated lungs. To investigate the microscopic origins of these changes, the alveolar walls were immunofluorescently labeled in small tissue strips. By using a fluorescent microscope, the lengths and angular orientations of individual alveolar walls were followed during cyclic uniaxial stretching of the tissue strips. The microstrains (relative change in segment length) and changes in angle of the alveolar walls showed considerable heterogeneity, which was interpreted in terms of a network model. In the normal strips, the alveolar walls showed larger angular changes compared with the treated tissue, whereas the alveolar walls of the treated tissue tended to be more extensible. Hysteresis in the average angle change was also larger in the treated tissue than in the normal tissue. We conclude that the decreased Ptp dependence of elastance and the constant hysteresivity in the treated lungs are related to microstructural remodeling and network phenomena at the level of the alveolar walls.

Computational model for forced expiration from asymmetric normal lungs

We present a computational model to predict maximal expiration through a morphometry-based asymmetrical bronchial tree. A computational model with the Horsfield-like geometry of the airway structure, including wave-speed flow limitation and taking into consideration separate airflows from several independent alveolar compartments has been derived. The airflow values are calculated for quasistatic conditions by solving a system of nonlinear differential equations describing static pressure losses along the airway branches. Calculations done for succeeding lung volumes result in the semidynamic maximal expiratory flow-volume (MEFV) curve. Simulations performed show that the model captures the main phenomena observed in vivo during forced expiration: effort independence of the flow-volume curve for the most of vital capacity, independence of limited flow on the properties of airways downstream to the choke points, characteristic differences of lung regional pressures and volumes, and a shape of their variability during exhalation. Some new insights into the flow limitation mechanism were achieved. First, flow limitation begins at slightly different time instants in individual branches of the bronchial tree, however after a short period of time, all regional flows are limited in a parallel fashion. Hence, total flow at the mouth is limited for most of the expired lung volume. Second, each of the airway branches contribute their own flow-volume shape and just these individual flows constitute the measured MEFV curve. Third, central airway heterogeneity can play a crucial role in modification of the entire flow. Fourth, the bronchial tree asymmetry is responsible for a nongravitational component of regional volume variability. Finally, increased inhomogeneity yields results that cannot be explained nor re-created with the use of a symmetrical structure of the bronchial tree.

Tracking variations in airway caliber by using total respiratory vs. airway resistance in healthy and asthmatic subjects

An index of airway caliber can be tracked in near-real time by measuring airway resistance (Raw) as indicated by lung resistance at 8 Hz. These measurements require the placing of an esophageal balloon. The objective of this study was to establish whether total respiratory system resistance (Rrs) could be used rather than Raw to track airway caliber, thereby not requiring an esophageal balloon. Rrs includes the resistance of the chest wall (Rcw). We used a recursive least squares approach to track Raw and Rrs at 8 Hz in seven healthy and seven asthmatic subjects during tidal breathing and a deep inspiration (DI). In both subject groups, Rrs was significantly higher than Raw during tidal breathing at baseline and postchallenge. However, at total lung capacity, Raw and Rrs became equivalent. Measured with this approach, Rcw appears volume dependent, having a magnitude of 0.5-1.0 cmH2O. l-1. s during tidal breathing and decreasing to zero at total lung capacity. When resistances are converted to an effective diameter, Rrs data overestimate the increase in diameter during a DI. Simulation studies suggest that the decrease in apparent Rcw during a DI is a consequence of airway opening flow underestimating chest wall flow at increased lung volume. We conclude that the volume dependence of Rcw can bias the presumed net change in airway caliber during tidal breathing and a DI but would not distort assessment of maximum airway dilation.

How does airway inflammation modulate asthmatic airway constriction? An antigen challenge study

During the late-phase (LP) response to inhaled allergen, mediators from neutrophils and eosinophils are released within the airways, resembling what occurs during an asthma attack. We compared the distribution of obstruction and degree of reversibility that follows a deep inspiration (DI) during early-phase (EP) and LP responses in nine asthmatic subjects challenged with allergen. Heterogeneity of constriction was assayed by determining frequency dependence of dynamic lung resistance and elastance, airway caliber by tracking airway resistance during a DI, and airway inflammation by measuring inflammatory cells in induced sputum postchallenge. Despite a paucity of eosinophils in the sputum at baseline (<1% of nonsquamous cells), asthmatic subjects showed a substantial EP response with highly heterogeneous constriction and reduced capacity to maximally dilate airways. The LP was associated with substantial airway inflammation in all subjects. However, five subjects showed only mild LP constriction, whereas four showed more marked LP constriction characterized by heterogeneous constriction similar to EP. Bronchoconstriction during LP was fully alleviated by administration of a bronchodilator. These findings, together with the impaired bronchodilatory response during a DI, indicate a physiological abnormality in asthma at the smooth muscle level and indicate that airway inflammation in asthma is associated with a highly nonuniform pattern of constriction. These data support the hypothesis that variability in responsiveness among asthmatic subjects derives from intrinsic differences in smooth muscle response to inflammation.

Variable ventilation induces endogenous surfactant release in normal guinea pigs

Variable or noisy ventilation, which includes random breath-to-breath variations in tidal volume (Vt) and frequency, has been shown to consistently improve blood oxygenation during mechanical ventilation in various models of acute lung injury. To further understand the effects of variable ventilation on lung physiology and biology, we mechanically ventilated 11 normal guinea pigs for 3 h using constant-Vt ventilation (n = 6) or variable ventilation (n = 5). After 3 h of ventilation, each animal underwent whole lung lavage for determination of alveolar surfactant content and composition, while protein content was assayed as a possible marker of injury. Another group of animals underwent whole lung lavage in the absence of mechanical ventilation to serve as an unventilated control group (n = 5). Although lung mechanics did not vary significantly between groups, we found that variable ventilation improved oxygenation, increased surfactant levels nearly twofold, and attenuated alveolar protein content compared with animals ventilated with constant Vt. These data demonstrate that random variations in Vt promote endogenous release of biochemically intact surfactant, which improves alveolar stability, apparently reducing lung injury.

Relation between structure, function, and imaging in a three-dimensional model of the lung

Previous studies have reported morphometric models to predict function relations in the lung. These models, however, are not anatomically explicit. We have advanced a three-dimensional airway tree model to relate dynamic lung function to alterations in structure, particularly when constriction patterns are imposed heterogeneously inspecific anatomic locations. First we predicted the sensitivity of dynamic lung resistance and elastance (RL and EL) to explicit forms of potential constriction patterns. Simulations show that severe and heterogeneous peripheral airway constriction confined to a single region in the lung (apex, mid, or base) will not produce substantial alterations in whole lung properties as measured from the airway opening. Conversely, when measured RL and EL are abnormal, it is likely that significant (but not necessarily homogeneous) constriction has occurred throughout the entire airway tree. We also introduce the concept of image-assisted modeling. Here positron emission tomographic imaging data sensitive to ventilation heterogeneity is synthesized with RL and EL data to help identify which airway constriction conditions could be consistent with both data sets. An ultimate goal would be personalized predictions.

Spatial distribution of human respiratory system transfer impedance

Transfer impedance (Ztr) of the respiratory system provides specific information on airways and tissues, but little is known about its spatial distribution in the different thoracoabdominal regions. To study Ztr distribution on the chest wall surface we analyzed five healthy subjects in the supine position by applying a sinusoidal forcing pressure (4, 8, and 12 Hz) at the mouth and measuring airway opening pressure and flow. Three-dimensional positions of 68 reflective markers placed on the chest wall over selected reference points were simultaneously measured by an optoelectronic motion analyzer. A subset of ten points placed on the midline were used to measure chest wall movements in the craniocaudal direction. While the motion of rib cage markers was synchronous, the abdominal markers demonstrated surface waves propagating caudally. The amplitude and phase of these waves were strongly dependent on position and frequency. We used a new method to measure total and local chest wall volume variations to compute the distribution of Ztr over the chest wall. Above 4 Hz we found that Ztr was inhomogeneously distributed and strongly dependent on position and frequency, mainly in the abdomen where the phase was often more more than 180 degrees with high values of modulus. For this reason, we conclude that above 8 Hz Ztr represents rib cage mechanics almost exclusively.

Variable tidal volume ventilation improves lung mechanics and gas exchange in a rodent model of acute lung injury

Random variations in breath rate and tidal volume during mechanical ventilation in the setting of acute lung injury have been shown to improve arterial oxygen tension. To test whether this improvement occurs over a specific range of variability, we examined several ventilation protocols in guinea pigs with endotoxin-induced lung injury. In Group I (n = 10), after 30 min of conventional volume-cycled ventilation, animals were ventilated with variable ventilation for 30-min intervals, during which time tidal volume was randomly varied by 10, 20, 40, and 60% of the mean, while simultaneously adjusting the frequency to maintain constant minute ventilation. In a second group of animals (Group II, n = 4), conventional volume-cycled ventilation was administered for 3 h. Variable ventilation significantly improved lung function over conventional volume-cycled ventilation. In Group I, lung elastance decreased, and blood oxygenation increased significantly during periods of 40 and 60% variable ventilation (p < 0.05) compared with conventional ventilation. These data indicate that variable ventilation is effective in improving lung function and gas exchange during acute lung injury.

Exact morphometric modeling of rat lungs for predicting mechanical impedance

We have developed a computational approach that allows for one-to-one mapping of the airway anatomy when predicting the overall lung mechanical properties and their response to explicit constriction patterns imposed on the airway tree. Specifically, we have exploited the database from Raabe et al. (LF-53 Albuquerque, NM: Lovelace foundation for radical Education and Research), to build the first anatomically based computational model of the rat. The model was then used to predict the response to homogeneous and heterogeneous peripheral airway constriction. Unlike in humans, the inherent asymmetry in the airway tree of rats is predicted to be a dominant contributor to the frequency dependence of lung resistance and elastance even if the constriction is imposed homogeneously. A similar approach would, in principal, be applicable for humans, but the Raabe data is not sufficiently complete to permit this.

Hysteresivity of the lung and tissue strip in the normal rat: effects of heterogeneities

We measured lung impedance in rats in closed chest (CC), open chest (OC), and isolated lungs (IL) at four transpulmonary pressures with a optimal ventilator waveform. Data were analyzed with an homogeneous linear or an inhomogeneous linear model. Both models include tissue damping and elastance and airway inertance. The homogeneous linear model includes airway resistance (Raw), whereas the inhomogeneous linear model has a continuous distribution of Raw characterized by the mean Raw and the standard deviation of Raw (SDR). Lung mechanics were compared with tissue strip mechanics at frequencies and operating stresses comparable to those during lung impedance measurements. The hysteresivity (eta) was calculated as tissue damping/elastance. We found that 1) airway and tissue parameters were different in the IL than in the CC and OC conditions; 2) SDR was lowest in the IL; and 3) eta in IL at low transpulmonary pressure was similar to eta in the tissue strip. We conclude that eta is primarily determined by lung connective tissue, and its elevated estimates from impedance data in the CC and OC conditions are a consequence of compartment-like heterogeneity being greater in CC and OC conditions than in the IL.

Airway constriction pattern is a central component of asthma severity: the role of deep inspirations

Measurements of lung resistance and elastance (RL and EL) from 0.1 to 8 Hz reflect both the mean level and pattern of lung constriction. The goal of this study was to establish a relation between a deep inspiration (DI) and the heterogeneity of constriction in healthy versus asthmatic subjects. Constriction pattern was assessed from measurements of the RL and EL from 0.1 to 8 Hz in seven healthy subjects and in 12 asthmatics. These data were acquired before and after a DI and before and after a standard methacholine challenge versus a modified challenge in which a DI is prohibited. Generally, avoidance of a DI increased responsiveness. In healthy subjects and in those with mild-to-moderate baseline asthma a bronchial challenge, especially during self-inhibited DI, produced a heterogenous pattern of constriction inclusive of randomly distributed airway closures or near closures. Nevertheless, such subjects were able to reopen their airways via a DI. In contrast, in subjects with severe baseline asthma, there is a more extreme heterogeneous constriction pattern with random airway closures even at baseline. Further, there is no residual bronchodilatory effect of a DI either before or after bronchial challenge. We conjecture that inflammation and wall-remodeling facilitate a dangerous degree of heterogeneous constriction inclusive of airway closures or near closures, and contribute to the prevention of a DI from having a residual bronchodilatory effect.

Selected contribution: airway caliber in healthy and asthmatic subjects: effects of bronchial challenge and deep inspirations

In 9 healthy and 14 asthmatic subjects before and after a standard bronchial challenge and a modified [deep inspiration (DI), inhibited] bronchial challenge and after albuterol, we tracked airway caliber by synthesizing a method to measure airway resistance (Raw; i.e., lung resistance at 8 Hz) in real time. We determined the minimum Raw achievable during a DI to total lung capacity and the subsequent dynamics of Raw after exhalation and resumption of tidal breathing. Results showed that even after a bronchial challenge healthy subjects can dilate airways maximally, and the dilation caused by a single DI takes several breaths to return to baseline. In contrast, at baseline, asthmatic subjects cannot maximally dilate their airways, and this worsens considerably postconstriction. Moreover, after a DI, the dilation that does occur in airway caliber in asthmatic subjects constricts back to baseline much faster (often after a single breath). After albuterol, asthmatic subjects could dilate airways much closer to levels of those of healthy subjects. These data suggest that the asthmatic smooth muscle resides in a stiffer biological state compared with the stimulated healthy smooth muscle, and inhibiting a DI in healthy subjects cannot mimic this.

Inspiratory lung impedance in COPD: effects of PEEP and immediate impact of lung volume reduction surgery

Frequency-dependent characteristics of lung resistance (RL) and elastance (EL) are sensitive to different patterns of airway obstruction. We used an enhanced ventilator waveform (EVW) to measure inspiratory RL and EL spectra in ventilated patients during thoracic surgery. The EVW delivers an inspiratory flow waveform with enhanced spectral excitation from 0.156 to 8.1 Hz. Estimates of the coefficients in a trigonometric approximation of the EVW flow and transpulmonary pressure inspirations yielded inspiratory RL and EL spectra. We applied the EVW in a group with mild obstruction undergoing various thoracoscopic procedures (n = 6), and another group with severe chronic obstructive pulmonary disease undergoing lung volume reduction surgery (n = 8). Measurements were made at positive end-expiratory pressure (PEEP) of 0, 3, and 6 cmH(2)O. Inspiratory RL was similar in both groups despite marked differences in spirometry. The chronic obstructive pulmonary disease patients demonstrated a pronounced frequency-dependent increase in inspiratory EL consistent with severe heterogeneous peripheral airway obstruction. PEEP appears to have beneficial effects by reducing peripheral airway resistance. Lung volume reduction surgery resulted in increased inspiratory RL and EL at all frequencies and PEEPs, possibly due to loss of diseased lung tissue, pulmonary edema, increased mechanical heterogeneity, and/or an improvement in airway tethering.

Fast, robust identification of nonlinear physiological systems using an implicit basis expansion

Because the number of parameters required by a Volterra series grows rapidly with both the length of its memory and the order of its nonlinearity, methods for identifying these models from measurements of input/output data are limited to low-order systems with relatively short memories. To deal with these computational and storage requirements one can either make extensive use of the structure of the Volterra series estimation problem to eliminate redundant storage and computations (e.g., the fast orthogonal algorithm), or apply a basis expansion, such as a Laguerre expansion, which seeks to reduce the number of model parameters, and hence, the size of the estimation problem. The use of an appropriate expansion basis can also decrease the noise sensitivity of the estimates. In this paper, we show how fast orthogonalization techniques can be combined with an expansion onto an arbitrary basis. We further demonstrate that the orthogonalization and expansion may be performed independently of each other. Thus, the results from a single application of the fast orthogonal algorithm can be used to generate multiple basis expansions. Simulations, using a simple nonlinear model of peripheral auditory processing, show the equivalence between the kernels estimated using a direct basis expansion, and those computed using the fast, implicit basis expansion technique which we propose. Running times for this new algorithm are compared to those for existing techniques.

Effects of collagenase and elastase on the mechanical properties of lung tissue strips

The dynamic stiffness (H), damping coefficient (G), and harmonic distortion (k(d)) characterizing tissue nonlinearity of lung parenchymal strips from guinea pigs were assessed before and after treatment with elastase or collagenase between 0.1 and 3.74 Hz. After digestion, data were obtained both at the same mean length and at the same mean force of the strip as before digestion. At the same mean length, G and H decreased by approximately 33% after elastase and by approximately 47% after collagenase treatment. At the same mean force, G and H increased by approximately 7% after elastase and by approximately 25% after collagenase treatment. The k(d) increased more after collagenase (40%) than after elastase (20%) treatment. These findings suggest that, after digestion, the fraction of intact fibers decreases, which, at the same mean length, leads to a decrease in moduli. At the same mean force, collagen fibers operate at a higher portion of their stress-strain curve, which results in an increase in moduli. Also, G and H were coupled so that hysteresivity (G/H) did not change after treatments. However, k(d) was decoupled from elasticity and was sensitive to stretching of collagen, which may be of value in detecting structural alterations in the connective tissue of the lung.

Parametric and nonparametric nonlinear system identification of lung tissue strip mechanics

Lung parenchyma is a soft biological material composed of many interacting elements such as the interstitial cells, extracellular collagen-elastin fiber network, and proteoglycan ground substance. The mechanical behavior of this delicate structure is complex showing several mild but distinct types of nonlinearities and a fractal-like long memory stress relaxation characterized by a power-law function. To characterize tissue nonlinearity in the presence of such long memory, we investigated the robustness and predictive ability of several nonlinear system identification techniques on stress-strain data obtained from lung tissue strips with various input wave forms. We found that in general, for a mildly nonlinear system with long memory, a nonparametric nonlinear system identification in the frequency domain is preferred over time-domain techniques. More importantly, if a suitable parametric nonlinear model is available that captures the long memory of the system with only a few parameters, high predictive ability with substantially increased robustness can be achieved. The results provide evidence that the first-order kernel of the stress-strain relationship is consistent with a fractal-type long memory stress relaxation and the nonlinearity can be described as a Wiener-type nonlinear structure for displacements mimicking tidal breathing.

Airway remodeling in asthma amplifies heterogeneities in smooth muscle shortening causing hyperresponsiveness

Although airway remodeling and inflammation in asthma can amplify the constriction response of a single airway, their influence on the structural changes in the whole airway network is unknown. We present a morphometric model of the human lung that incorporates cross-sectional wall areas corresponding to the adventitia, airway smooth muscle (ASM), and mucosa for healthy and mildly and severely asthmatic airways and the influence of parenchymal tethering. A heterogeneous ASM percent shortening stimulus is imposed, causing distinct constriction patterns for healthy and asthmatic airways. We calculate lung resistance and elastance from 0.1 to 5 Hz. We show that, for a given ASM stimulus, the distribution of wall area in asthmatic subjects will amplify not only the mean but the heterogeneity of constriction in the lung periphery. Moreover, heterogeneous ASM shortening that would produce only mild changes in the healthy lung can cause hyperresponsive changes in lung resistance and elastance at typical breathing rates in the asthmatic lung, even with relatively small increases in airway resistance. This condition arises when airway closures occur randomly in the lung periphery. We suggest that heterogeneity is a crucial determinant of hyperresponsiveness in asthma and that acute asthma is more a consequence of extensive airway wall inflammation and remodeling, predisposing the lung to produce an acute pattern of heterogeneous constriction.

Technique to determine inspiratory impedance during mechanical ventilation: implications for flow limited patients

We present the design of an enhanced ventilator waveform (EVW) for routine measurement of inspiratory resistance (R) and elastance (E) spectra in ventilator-dependent and/or severely obstructed flow-limited patients. The EVW delivers an inspiratory tidal volume of fresh gas with a flow pattern consisting of multiple sinusoids from 0.156 to 8.1 Hz and permits a patient-driven exhalation to the atmosphere or positive end-expiratory pressure. Weighted least-squares estimates of the coefficients in a sinusoidal series approximation of the EVW inspirations yielded inspiratory R and E spectra. We first validated the EVW approach using simulated pressure and flow data under different physiological conditions, noise levels, and harmonic distortions. We then applied the EVW in four intubated patients during anesthesia and paralysis: two with mild airway obstruction and two with severe emphysema and flow limitation. While the level of inspiratory R was similar in both groups of patients, the inspiratory E of the emphysematous patients demonstrated a pronounced frequency-dependent increase consistent with severe peripheral airway obstruction. We conclude that the EVW offers a potentially practical and efficient approach to monitor lung function in ventilator-dependent patients, especially those with expiratory flow limitation.

Airway and lung tissue mechanics in asthma. Effects of albuterol

We examined the partitioning of total lung resistance (RL) into airway resistance (Raw) and tissue resistance (Rti) in patients with mild to moderate asthma (baseline FEV1, 54 to 91% of predicted) before and after albuterol inhalation. An optimal ventilator waveform was used to measure RL and lung elastance (EL) in 21 asthmatics from approximately 0.1 to 8 Hz during tidal excursions. Analysis of the RL and EL provided separate estimates of airway and lung tissue properties. Eleven subjects, classified as Type A asthmatics, displayed slightly elevated RL but normal EL. Their data were well described with a model consisting of homogeneous airways leading to viscoelastic tissues before and after albuterol. The other 10 subjects, classified as Type B asthmatics, demonstrated highly elevated RL and an EL that became highly elevated at frequencies above 2 Hz. These subjects required the inclusion of an airway wall compliance in the model prealbuterol but not postalbuterol. This suggests that the Type B subjects were experiencing pronounced constriction in the periphery of the lung, resulting in shunting of flow into the airway walls. Spirometric data were consistent with higher constriction in Type B subjects. Both groups demonstrated significant (p < 0.05) decreases in Raw and tissue damping after albuterol, but tissue elastance decreased only in the Type B group. The percent contributions of Raw and Rti to RL were similar in both groups and did not change after albuterol. We conclude that in asthma, Raw comprises the majority (> 70%) of RL at breathing frequencies. The relative contributions of Raw and Rti to RL appear to be independent of the degree of smooth muscle constriction.