Patterns of recruitment and injury in a heterogeneous airway network model

Which airways should we treat? Structure-function relationships and estimation of the singular input modes from the forward model alone

Structure-function relationships occur throughout the sciences. Motivated by optimization of such systems, we develop a framework for estimating the input modes from the singular value decomposition from the action of the forward operator alone. These can then be used to determine the input (structure) changes, which induce the largest output (function) changes. The accuracy of the estimate is determined by reference to the method of snapshots. The proposed method is demonstrated on several example problems, and finally used to approximate the optimal airway treatment set for a problem in respiratory physiology.

Full-lung simulations of mechanically ventilated lungs incorporating recruitment/derecruitment dynamics

This study developed and investigated a comprehensive multiscale computational model of a mechanically ventilated ARDS lung to elucidate the underlying mechanisms contributing to the development or prevention of VILI. This model is built upon a healthy lung model that incorporates realistic airway and alveolar geometry, tissue distensibility, and surfactant dynamics. Key features of the ARDS model include recruitment and derecruitment (RD) dynamics, alveolar tissue viscoelasticity, and surfactant deficiency. This model successfully reproduces realistic pressure-volume (PV) behavior, dynamic surface tension, and time-dependent descriptions of RD events as a function of the ventilation scenario. Simulations of Time-Controlled Adaptive Ventilation (TCAV) modes, with short and long durations of exhalation (T Low - and T Low +, respectively), reveal a higher incidence of RD for T Low + despite reduced surface tensions due to interfacial compression. This finding aligns with experimental evidence emphasizing the critical role of timing in protective ventilation strategies. Quantitative analysis of energy dissipation indicates that while alveolar recruitment contributes only a small fraction of total energy dissipation, its spatial concentration and brief duration may significantly contribute to VILI progression due to its focal nature and higher intensity. Leveraging the computational framework, the model may be extended to facilitate the development of personalized protective ventilation strategies to enhance patient outcomes. As such, this computational modeling approach offers valuable insights into the complex dynamics of VILI that may guide the optimization of ventilation strategies in ARDS management.

Modeling Mechanical Ventilation In Silico-Potential and Pitfalls

Computer simulation offers a fresh approach to traditional medical research that is particularly well suited to investigating issues related to mechanical ventilation. Patients receiving mechanical ventilation are routinely monitored in great detail, providing extensive high-quality data-streams for model design and configuration. Models based on such data can incorporate very complex system dynamics that can be validated against patient responses for use as investigational surrogates. Crucially, simulation offers the potential to "look inside" the patient, allowing unimpeded access to all variables of interest. In contrast to trials on both animal models and human patients, in silico models are completely configurable and reproducible; for example, different ventilator settings can be applied to an identical virtual patient, or the same settings applied to different patients, to understand their mode of action and quantitatively compare their effectiveness. Here, we review progress on the mathematical modeling and computer simulation of human anatomy, physiology, and pathophysiology in the context of mechanical ventilation, with an emphasis on the clinical applications of this approach in various disease states. We present new results highlighting the link between model complexity and predictive capability, using data on the responses of individual patients with acute respiratory distress syndrome to changes in multiple ventilator settings. The current limitations and potential of in silico modeling are discussed from a clinical perspective, and future challenges and research directions highlighted.

Potential effect of pulmonary fluid viscosity on positive end-expiratory pressure and regional distribution of lung ventilation in acute respiratory distress syndrome

BACKGROUND

Computational fluid dynamic simulations have showed that the elevated viscosity of pulmonary fluids may increase the likelihood of airway closure, thus exacerbating inhomogeneity of regional lung ventilation. Unfortunately, there have been few studies directed toward measurements of viscosity of pulmonary fluids and its effect on airway opening pressure and regional distribution of lung ventilation in acute respiratory distress syndrome.

METHODS

In this study, pulmonary fluids from 8 ARDS patients were measured using a cone and plate rheometer on days 1, 3, 7 and 14 in the treatment of the disorder. Ventilator settings were simultaneously recorded, including tidal volume, positive end-expiratory pressure, fraction of inspired oxygen (FiO₂), and so on. The regional distribution of lung ventilation was monitored by a bedside electrical impedance tomography system.

FINDINGS

The results showed that rheological properties of pulmonary fluids behaved as either Newtonian or non-Newtonian across all patients studied. Significant intersubject and intrasubject variations in measured viscosities were observed, spanning ranges from approximately 1 cP to 7 × 10⁴ cP at shear rates between 0.075-750 s^-1. The product of the positive end-expiratory airway pressure and fraction of inspired oxygen was well correlated with fluid viscosity in patients with high viscosity pulmonary fluids. Furthermore, lung ventilation in these patients was highly inhomogeneous and influenced by rheology of pulmonary fluids.

INTERPRETATION

The current findings provided the direct clinical data for theoretical models of airway reopening and may have important clinical implications in explaining inhomogeneity of lung ventilation and selecting initial levels of positive end-expiratory pressure in mechanically ventilated patients.

The steady motion of microbubbles in bifurcating airways: Role of shear-thinning and surface tension

Mucous fluid is non-Newtonian secretions in the lower lung airways that accumulates when the alveolar-capillary membrane ruptures during acute respiratory distress syndrome. The mucus fluid has, therefore, different types of non-Newtonian properties like shear-thinning, viscoelasticity, and non-zero yield stress. In this paper, we numerically solved the steady Stokes equations along with arbitrary Eulerian-Lagrangian moving mesh techniques to study the microbubble propagation in a two-dimensional asymmetric bifurcating airway filled with non-Newtonian fluid where the fluid has shear-thinning behavior described by the power-law model. Numerical results show that both shear-thinning and surface tension characterized by the behavior index (n) and Capillary number (Ca), respectively, had a significant impact on microbubble flow patterns and the magnitude of the pressure gradient. At low values of both n and Ca, the microbubble leaves a thin film-thickness with the airway wall while a large and sharp peak of the pressure gradient near the thin bubble tip. Interestingly, increasing both n and Ca, leads to an increase in film thickness and a decrease in the pressure gradient magnitude in both the daughter airway walls. It is observed the magnitude of the pressure gradient is more sensitive to Ca compared to n. We concluded that shear-thinning and surface tension not only significantly impact the patterns of microbubble propagation but also the hydrodynamic stress magnitudes at the airway wall.

Mathematical modeling of ventilator-induced lung inflammation

Despite the benefits of mechanical ventilators, prolonged or misuse of ventilators may lead to ventilation-associated/ventilation-induced lung injury (VILI). Lung insults, such as respiratory infections and lung injuries, can damage the pulmonary epithelium, with the most severe cases needing mechanical ventilation for effective breathing and survival. Damaged epithelial cells within the alveoli trigger a local immune response. A key immune cell is the macrophage, which can differentiate into a spectrum of phenotypes ranging from pro- to anti-inflammatory. To gain a greater understanding of the mechanisms of the immune response to VILI and post-ventilation outcomes, we developed a mathematical model of interactions between the immune system and site of damage while accounting for macrophage phenotype. Through Latin hypercube sampling we generated a collection of parameter sets that are associated with a numerical steady state. We then simulated ventilation-induced damage using these steady state values as the initial conditions in order to evaluate how baseline immune state and lung health affect outcomes. We used a variety of methods to analyze the resulting parameter sets, transients, and outcomes, including a random forest decision tree algorithm and parameter sensitivity with eFAST. Analysis shows that parameters and properties of transients related to epithelial repair and M1 activation are important factors. Using the results of this analysis, we hypothesized interventions and used these treatment strategies to modulate the response to ventilation for particular parameters sets.

Phenotype- and patient-specific modelling in asthma: Bronchial thermoplasty and uncertainty quantification

Theoretical models can help to overcome experimental limitations to better our understanding of lung physiology and disease. While such efforts often begin in broad terms by determining the effect of a disease process on a relevant biological output, more narrowly defined simulations may inform clinical practice. Two such examples are phenotype-specific and patient-specific models, the former being specific to a group of patients with common characteristics, and the latter to an individual patient, in view of likely differences (heterogeneity) between patients. However, in order for such models to be useful, they must be sufficiently accurate, given the available data about the specific characteristics of the patient. We show that, for asthma in particular, this approach is promising: phenotype-specific targeting may be an effective way of selecting patients for treatment based on their airway remodelling phenotype, and patient-specific targeting may be viable with the use of a clinically-plausible dataset. Specifically we consider asthma and its treatment by bronchial thermoplasty, in which the airway smooth muscle layer is directly targeted by thermal energy. Patient-specific and phenotype-specific models in this context are considered using a combination of biobank data from ex vivo tissue samples, CT imaging, and optical coherence tomography which allows more detailed resolution of the airway wall structures.

Mechanical Ventilation Lessons Learned From Alveolar Micromechanics

Morbidity and mortality associated with lung injury remains disappointingly unchanged over the last two decades, in part due to the current reliance on lung macro-parameters set on the ventilator instead of considering the micro-environment and the response of the alveoli and alveolar ducts to ventilator adjustments. The response of alveoli and alveolar ducts to mechanical ventilation modes cannot be predicted with current bedside methods of assessment including lung compliance, oxygenation, and pressure-volume curves. Alveolar tidal volumes (Vt) are less determined by the Vt set on the mechanical ventilator and more dependent on the number of recruited alveoli available to accommodate that Vt and their heterogeneous mechanical properties, such that high lung Vt can lead to a low alveolar Vt and low Vt can lead to high alveolar Vt. The degree of alveolar heterogeneity that exists cannot be predicted based on lung calculations that average the individual alveolar Vt and compliance. Finally, the importance of time in promoting alveolar stability, specifically the inspiratory and expiratory times set on the ventilator, are currently under-appreciated. In order to improve outcomes related to lung injury, the respiratory physiology of the individual patient, specifically at the level of the alveolus, must be targeted. With experimental data, this review highlights some of the known mechanical ventilation adjustments that are helpful or harmful at the level of the alveolus.

A Distribution-Moment Approximation for Coupled Dynamics of the Airway Wall and Airway Smooth Muscle

Asthma is fundamentally a disease of airway constriction. Due to a variety of experimental challenges, the dynamics of airways are poorly understood. Of specific interest is the narrowing of the airway due to forces produced by the airway smooth muscle wrapped around each airway. The interaction between the muscle and the airway wall is crucial for the airway constriction that occurs during an asthma attack. Although cross-bridge theory is a well-studied representation of complex smooth muscle dynamics, and these dynamics can be coupled to the airway wall, this comes at significant computational cost-even for isolated airways. Because many phenomena of interest in pulmonary physiology cannot be adequately understood by studying isolated airways, this presents a significant limitation. We present a distribution-moment approximation of this coupled system and study the validity of the approximation throughout the physiological range. We show that the distribution-moment approximation is valid in most conditions, and we explore the region of breakdown. These results show that in many situations, the distribution-moment approximation is a viable option that provides an orders-of-magnitude reduction in computational complexity; not only is this valuable for isolated airway studies, but it moreover offers the prospect that rich ASM dynamics might be incorporated into interacting airway models where previously this was precluded by computational cost.

Inter-airway structural heterogeneity interacts with dynamic heterogeneity to determine lung function and flow patterns in both asthmatic and control simulated lungs

Asthma is a disease involving both airway remodelling (e.g. thickening of the airway wall) and acute, reversible airway narrowing driven by airway smooth muscle contraction. Both of these processes are known to be heterogeneous, and in this study we consider a new theoretical model which considers the interactions of both mechanisms: structural heterogeneity (variation in airway remodelling) and dynamic heterogeneity (emergent variation in airway narrowing and flow). By integrating both types of inter-airway heterogeneity in a full human lung geometry, we are able to draw several insights regarding the mechanisms underlying observed ventilation heterogeneity. We show that: (1) bimodal ventilation distributions are driven by paradoxical contraction/dilation patterns for airways of all sizes; (2) structural heterogeneity differences between asthmatic and control subjects significantly influences resulting lung function, and observed ventilation heterogeneity patterns; and (3) individual airway dilation probabilities are uncorrelated with prior airway remodelling of that airway.

Dynamics of liquid plugs in prewetted capillary tubes: from acceleration and rupture to deceleration and airway obstruction

The dynamics of individual liquid plugs pushed at a constant pressure head inside prewetted cylindrical capillary tubes is investigated experimentally and theoretically. It is shown that, depending on the thickness of the prewetting film and the magnitude of the pressure head, the plugs can either experience a continuous acceleration leading to a dramatic decrease of their size and eventually their rupture or conversely, a progressive deceleration associated with their growth and an exacerbation of the airway obstruction. These behaviors are quantitatively reproduced using a simple nonlinear model [Baudoin et al., Proc. Natl. Acad. Sci. U. S. A., 2013, 110, 859] adapted here for cylindrical channels. Furthermore, an analytical criterion for the transition between these two regimes is derived and successfully compared with extensive experimental data. The potential implications of this work for pulmonary obstructive diseases are discussed.

Clustered ventilation defects and bilinear respiratory reactance in asthma

Imaging studies of asthmatics typically reveal clustered ventilation patterns, rather than homogeneous ventilation; furthermore, the variation of these clusters suggests that the causes are at least partially dynamic, rather than structural. Theoretical studies have indicated dynamic mechanisms by which homogeneous ventilation solutions lose stability and clustered solutions emerge. At the same time, it has been demonstrated experimentally that respiratory reactance characteristically has a bilinear relationship with lung volume, and that changes to this relationship are indicative of various aspects of disease progression and control. Moreover, the transition point in the bilinear reactance relationship is thought to relate to reopening/recruitment of airway units, and thus may be connected to the bifurcation via which clustered ventilation solutions emerge. In order to investigate this possibility we develop a new model, including both airway-airway coupling and airway-parenchymal coupling, which exhibits both clustered ventilation defects and also a bilinear reactance relationship. Studying this model reveals that (1) the reactance breakpoint is not coincident with the bifurcation; (2) numerous changes to underlying behaviour can alter the reactance breakpoint in ways which mimic the experimental data; and (3) the location of ventilation defects can be a combination of both structural and dynamic factors.

Systems-level airway models of bronchoconstriction

Understanding lung and airway behavior presents a number of challenges, both experimental and theoretical, but the potential rewards are great in terms of both potential treatments for disease and interesting biophysical phenomena. This presents an opportunity for modeling to contribute to greater understanding, and here, we focus on modeling efforts that work toward understanding the behavior of airways in vivo, with an emphasis on asthma. We look particularly at those models that address not just isolated airways but many of the important ways in which airways are coupled both with each other and with other structures. This includes both interesting phenomena involving the airways and the layer of airway smooth muscle that surrounds them, and also the emergence of spatial ventilation patterns via dynamic airway interaction. WIREs Syst Biol Med 2016, 8:459-467. doi: 10.1002/wsbm.1349 For further resources related to this article, please visit the WIREs website.