Effect of inspiratory flow rate on regional distribution of inspired gas

Respiratory Tract Deposition of E-Cigarette Particles

Total and regional deposition of inhaled electronic cigarette (E-cig) particles in the respiratory tract (RT) depends on both physical properties of the inhaled particles and biological factors of users, for example, breathing pattern or puff profile, airway anatomy, and regional ventilation. Accurate particle sizing of E-cig aerosols is essential for predicting particle deposition in the RT. Studies using a variety of sizing methods have shown mass median aerodynamic diameters ranging from 0.2 to 1.2 um and secondary count diameters in the ultrafine range (<0.1 μm). Incorporating these particle sizes into a multiple-path particle dosimetry (MPPD) model shows 10% to 45% total lung deposition by mass and 30% to 80% for ultrafine particles depending on the breathing patterns. These predictions are consistent with experimental measures of deposition fraction of submicron and ultrafine particles. While box-mod-type E-cig devices allow for full "direct-lung" inhalations of aerosol, the more recent pod-based, and disposable E-cigs (e.g., JUUL, Puff Bar, Stig) deliver the aerosol as a "mouth-to-lung" puff, or bolus, that is inhaled early in the breath followed to various degrees by further inhalation of ambient air. Measurement of realistic ventilation patterns associated with these various devices may further improve deposition predictions. Finally, while in vivo measures of RT deposition present a challenge, a recent methodology to radiolabel E-cig particles may allow for such measurements by gamma scintigraphy. Supported by NIH/NHLBI R01HL139369. © 2022 American Physiological Society. Compr Physiol 12: 1-10, year.

Is the healthy respiratory system built just right, overbuilt, or underbuilt to meet the demands imposed by exercise?

In the healthy, untrained young adult, a case is made for a respiratory system (airways, pulmonary vasculature, lung parenchyma, respiratory muscles, and neural ventilatory control system) that is near ideally designed to ensure a highly efficient, homeostatic response to exercise of varying intensities and durations. Our aim was then to consider circumstances in which the intra/extrathoracic airways, pulmonary vasculature, respiratory muscles, and/or blood-gas distribution are underbuilt or inadequately regulated relative to the demands imposed by the cardiovascular system. In these instances, the respiratory system presents a significant limitation to O₂ transport and contributes to the occurrence of locomotor muscle fatigue, inhibition of central locomotor output, and exercise performance. Most prominent in these examples of an "underbuilt" respiratory system are highly trained endurance athletes, with additional influences of sex, aging, hypoxic environments, and the highly inbred equine. We summarize by evaluating the relative influences of these respiratory system limitations on exercise performance and their impact on pathophysiology and provide recommendations for future investigation.

Effects of inspiratory flow on lung stress, pendelluft, and ventilation heterogeneity in ARDS: a physiological study

Background

High inspiratory flow might damage the lungs by mechanisms not fully understood yet. We hypothesized that increasing inspiratory flow would increase lung stress, ventilation heterogeneity, and pendelluft in ARDS patients undergoing volume-controlled ventilation with constant tidal volume and that higher PEEP levels would reduce this phenomenon.

Methods

Ten ARDS patients were studied during protective volume-controlled ventilation. Three inspiratory flows (400, 800, and 1200 ml/s) and two PEEP levels (5 and 15 cmH₂O) were applied in random order to each patient. Airway and esophageal pressures were recorded, end-inspiratory and end-expiratory holds were performed, and ventilation distribution was measured with electrical impedance tomography. Peak and plateau airway and transpulmonary pressures were recorded, together with the airway and transpulmonary pressure corresponding to the first point of zero end-inspiratory flow (P1). Ventilation heterogeneity was measured by the EIT-based global inhomogeneity (GI) index. Pendelluft was measured as the absolute difference between pixel-level inflation measured at plateau pressure minus P1.

Results

Plateau airway and transpulmonary pressure was not affected by inspiratory flow, while P1 increased at increasing inspiratory flow. The difference between P1 and plateau pressure was higher at higher flows at both PEEP levels (p < 0.001). While higher PEEP reduced heterogeneity of ventilation, higher inspiratory flow increased GI (p = 0.05), irrespective of the PEEP level. Finally, gas volume undergoing pendelluft was larger at higher inspiratory flow (p < 0.001), while PEEP had no effect.

Conclusions

The present exploratory analysis suggests that higher inspiratory flow increases additional inspiratory pressure, heterogeneity of ventilation, and pendelluft while PEEP has negligible effects on these flow-dependent phenomena. The clinical significance of these findings needs to be further clarified.

Assessment Of Changes In Regional Xenon-Ventilation, Perfusion, And Ventilation-Perfusion Mismatch Using Dual-Energy Computed Tomography After Pharmacological Treatment In Patients With Chronic Obstructive Pulmonary Disease: Visual And Quantitative Analysis

Purpose

To assess changes in regional ventilation (V), perfusion (Q), and V-Q mismatch in patients with chronic obstructive pulmonary disease (COPD) after pharmacologic treatment using combined xenon-enhanced V and iodine-enhanced Q dual-energy CT (DECT).

Patients and methods

Combined V and Q DECT were performed at baseline and after three-month pharmacologic treatment in 52 COPD patients. Anatomically co-registered virtual non-contrast images, V, Q, and V/Q_ratio maps were obtained. V/Q pattern was visually determined to be matched, mismatched, or reversed-mismatched and compared with the regional parenchymal disease patterns of each segment. DECT parameters for V, Q, and V-Q imbalance were quantified.

Results

The parenchymal patterns on CT were not changed at follow-up. The segments with matched V/Q pattern were increased (80.2% to 83.6%) as the segments with reversed-mismatched V/Q pattern were decreased with improving ventilation (17.6% to 13.8%) after treatment. Changes of V/Q patterns were mostly observed in segments with bronchial wall thickening. Compared with patients without bronchial wall thickening, the quantified DECT parameters of V-Q imbalance were significantly improved in patients with bronchial wall thickening (p < 0.05). Changes in forced expiratory volume in one second after treatment were correlated with changes in the quantified DECT parameters (r = 0.327–0.342 or r = −0.406 and −0.303; p < 0.05).

Conclusion

DECT analysis showed that the V-Q imbalance was improved after the pharmacological treatment in COPD patients, although the parenchymal disease patterns remained unchanged. This improvement of V-Q imbalance may occur mostly in the areas with bronchial wall thickening.

Optimization of dual-energy xenon-computed tomography for quantitative assessment of regional pulmonary ventilation

OBJECTIVE

Dual-energy x-ray computed tomography (DECT) offers visualization of the airways and quantitation of regional pulmonary ventilation using a single breath of inhaled xenon gas. In this study, we sought to optimize scanning protocols for DECT xenon gas ventilation imaging of the airways and lung parenchyma and to characterize the quantitative nature of the developed protocols through a series of test-object and animal studies.

MATERIALS AND METHODS

The Institutional Animal Care and Use Committee approved all animal studies reported here. A range of xenon/oxygen gas mixtures (0%, 20%, 25%, 33%, 50%, 66%, 100%; balance oxygen) were scanned in syringes and balloon test-objects to optimize the delivered gas mixture for assessment of regional ventilation while allowing for the development of improved 3-material decomposition calibration parameters. In addition, to alleviate gravitational effects on xenon gas distribution, we replaced a portion of the oxygen in the xenon/oxygen gas mixture with helium and compared gas distributions in a rapid-prototyped human central-airway test-object. Additional syringe tests were performed to determine if the introduction of helium had any effect on xenon quantitation. Xenon gas mixtures were delivered to anesthetized swine to assess airway and lung parenchymal opacification while evaluating various DECT scan acquisition settings.

RESULTS

Attenuation curves for xenon were obtained from the syringe test-objects and were used to develop improved 3-material decomposition parameters (Hounsfield unit enhancement per percentage xenon: within the chest phantom, 2.25 at 80 kVp, 1.7 at 100 kVp, and 0.76 at 140 kVp with tin filtration; in open air, 2.5 at 80 kVp, 1.95 at 100 kVp, and 0.81 at 140 kVp with tin filtration). The addition of helium improved the distribution of xenon gas to the gravitationally nondependent portion of the airway tree test-object, while not affecting the quantitation of xenon in the 3-material decomposition DECT. The mixture 40% Xe/40% He/20% O2 provided good signal-to-noise ratio (SNR), greater than the Rose criterion (SNR > 5), while avoiding gravitational effects of similar concentrations of xenon in a 60% O2 mixture. Compared with 100/140 Sn kVp, 80/140 Sn kVp (Sn = tin filtered) provided improved SNR in a swine with an equivalent thoracic transverse density to a human subject with a body mass index of 33 kg/m. Airways were brighter in the 80/140 Sn kVp scan (80/140 Sn, 31.6%; 100/140 Sn, 25.1%) with considerably lower noise (80/140 Sn, coefficient of variation of 0.140; 100/140 Sn, coefficient of variation of 0.216).

CONCLUSION

To provide a truly quantitative measure of regional lung function with xenon-DECT, the basic protocols and parameter calibrations need to be better understood and quantified. It is critically important to understand the fundamentals of new techniques to allow for proper implementation and interpretation of their results before widespread usage. With the use of an in-house derived xenon calibration curve for 3-material decomposition rather than the scanner supplied calibration and a xenon/helium/oxygen mixture, we demonstrate highly accurate quantitation of xenon gas volumes and avoid gravitational effects on gas distribution. This study provides a foundation for other researchers to use and test these methods with the goal of clinical translation.

Airway gas flow

Local characteristics of airflow and its global distribution in the lung are determined by interaction between resistance to flow through the airways and the compliance of the tissue, with tissue compliance dominating flow distribution in the healthy lung. Current understanding is that conceptualizing the airways of the lung as a system of smooth adjoined cylinders through which air traverses laminarly is insufficient for understanding flow and energy dissipation and is particularly poor for predicting physiologically realistic transport of particles by the airflow. With rapid advances in medical imaging, computer technologies, and computational techniques, computational fluid dynamics is now becoming a viable tool for providing detailed information on the mechanics of airflow in the human respiratory tract. Studies using such techniques have shown that the upper airway (specifically its development of a turbulent laryngeal jet in the trachea), airway geometry, branching and rotation angle, and the pattern of joining of successive bifurcations are important in determining airflow structures. It is now possible to compute airflow in physical domains that are anatomically accurate and subject specific, enabling comparisons among intersubjects, that among subjects of different ages, and that among different species.

Peripheral circulation

Blood flow (BF) increases with increasing exercise intensity in skeletal, respiratory, and cardiac muscle. In humans during maximal exercise intensities, 85% to 90% of total cardiac output is distributed to skeletal and cardiac muscle. During exercise BF increases modestly and heterogeneously to brain and decreases in gastrointestinal, reproductive, and renal tissues and shows little to no change in skin. If the duration of exercise is sufficient to increase body/core temperature, skin BF is also increased in humans. Because blood pressure changes little during exercise, changes in distribution of BF with incremental exercise result from changes in vascular conductance. These changes in distribution of BF throughout the body contribute to decreases in mixed venous oxygen content, serve to supply adequate oxygen to the active skeletal muscles, and support metabolism of other tissues while maintaining homeostasis. This review discusses the response of the peripheral circulation of humans to acute and chronic dynamic exercise and mechanisms responsible for these responses. This is accomplished in the context of leading the reader on a tour through the peripheral circulation during dynamic exercise. During this tour, we consider what is known about how each vascular bed controls BF during exercise and how these control mechanisms are modified by chronic physical activity/exercise training. The tour ends by comparing responses of the systemic circulation to those of the pulmonary circulation relative to the effects of exercise on the regional distribution of BF and mechanisms responsible for control of resistance/conductance in the systemic and pulmonary circulations.

High correlation of the response of upper and lower lobe small airway epithelium to smoking

The distribution of lung disease induced by inhaled cigarette smoke is complex, depending on many factors. With the knowledge that the small airway epithelium (SAE) is the earliest site of smoking-induced lung disease, and that the SAE gene expression is likely sensitive to inhaled cigarette smoke, we compared upper vs. lower lobe gene expression in the SAE within the same cigarette smokers to determine if the gene expression patterns were similar or different. Active smokers (n = 11) with early evidence of smoking-induced lung disease (normal spirometry but low diffusing capacity) underwent bronchoscopy and brushing of the upper and lower lobe SAE in order to compare upper vs lower lobe genome-wide and smoking-responsive gene expression by microarray. Cluster and principal component analysis demonstrated that, for each individual, the expression of the known SAE smoking-responsive genes were highly correlated in upper and lower lobe pairs, although, as expected, there were differences in the smoking-induced changes in gene expression from individual to individual. These observations support the concept that the heterogeneity observed among smokers in the anatomic distribution of smoking-induced disease are not secondary to the topographic differences in the effects of cigarette smoke on the airway epithelium.

Regional lung ventilation in humans during hypergravity studied with quantitative SPECT

Recently we challenged the view that arterial desaturation during hypergravity is caused by redistribution of blood flow to dependent lung regions by demonstrating a paradoxical redistribution of blood flow towards non-dependent regions. We have now quantified regional ventilation in 10 healthy supine volunteers at normal and three times normal gravity (1G and 3G). Regional ventilation was measured with Technegas ((99m)Tc) and quantitative single photon emission computed tomography (SPECT). Hypergravity caused arterial desaturation, mean decrease 8%, p<0.05 vs. 1G. The ratio for mean ventilation per voxel for non-dependent and dependent lung regions was 0.81±0.12 during 1G and 1.63±0.35 during 3G (mean±SD), p<0.0001. Thus, regional ventilation was shifted from dependent to non-dependent regions. We suggest that arterial desaturation during hypergravity is caused by quantitatively different redistributions of blood flow and ventilation. To our knowledge, this is the first study presenting high-resolution measurements of regional ventilation in humans breathing normally during hypergravity.

Quantitative lung SPECT applied on simulated early COPD and humans with advanced COPD

BACKGROUND

Reduced ventilation in lung regions affected by chronic obstructive pulmonary disease (COPD), reflected as inhomogeneities in the single-photon emission computed tomography (SPECT) lung image, is correlated to disease advancement. An analysis method for measuring these inhomogeneities is proposed in this work. The first aim was to develop a quantitative analysis method that could discriminate between Monte Carlo simulated normal and COPD lung SPECT images. A second aim was to evaluate the ability of the present method to discriminate between human subjects with advanced COPD and healthy volunteers.

METHODS

In the simulated COPD study, different activity distributions in the lungs were created to mimic the healthy lung (normal) and different levels of COPD. Gamma camera projections were Monte Carlo simulated, representing clinically acquired projections of a patient who had inhaled 125 MBq 99mTc-Technegas followed by a 10-min SPECT examination. Reconstructions were made with iterative ordered subset expectation maximisation. The coefficient of variance (CV) was calculated for small overlapping volumes covering the 3D reconstructed activity distribution. A CV threshold value (CVT) was calculated as the modal value of the CV distribution of the simulated normal. The area under the distribution curve (AUC), for CV values greater than CVT, AUC(CVT), was then calculated. Moreover, five patients with advanced emphysema and five healthy volunteers inhaled approximately 75 MBq 99mTc-Technegas immediately before the 20-min SPECT acquisition. In the human study, CVT was based on the mean CV distribution of the five healthy volunteers.

RESULTS

A significant difference (p < 0.001) was found between the Monte-Carlo simulated normal and COPD lung SPECT examinations. The present method identified a total reduction of ventilation of approximately 5%, not visible to the human eye in the reconstructed image. In humans the same method clearly discriminated between the five healthy volunteers and five patients with advanced COPD (p < 0.05).

CONCLUSIONS

While our results are promising, the potential of the AUC(CVT) method to detect less advanced COPD in patients needs further clinical studies.

Accelerated fractional ventilation imaging with hyperpolarized Gas MRI

PURPOSE

To investigate the utility of accelerated imaging to enhance multibreath fractional ventilation (r) measurement accuracy using hyperpolarized gas MRI. Undersampling shortens the breath-hold time, thereby reducing the O2 -induced signal decay and allows subjects to maintain a more physiologically relevant breathing pattern. Additionally, it may improve r estimation accuracy by reducing radiofrequency destruction of hyperpolarized gas.

METHODS

Image acceleration was achieved using an eight-channel phased array coil. Undersampled image acquisition was simulated in a series of ventilation images and data was reconstructed for various matrix sizes (48-128) using generalized auto-calibrating partially parallel acquisition. Parallel accelerated r imaging was also performed on five mechanically ventilated pigs.

RESULTS

Optimal acceleration factor was fairly invariable (2.0-2.2×) over the range of simulated resolutions. Estimation accuracy progressively improved with higher resolutions (39-51% error reduction). In vivo r values were not significantly different between the two methods: 0.27 ± 0.09, 0.35 ± 0.06, 0.40 ± 0.04 (standard) versus 0.23 ± 0.05, 0.34 ± 0.03, 0.37 ± 0.02 (accelerated); for anterior, medial, and posterior slices, respectively, whereas the corresponding vertical r gradients were significant (P < 0.001): 0.021 ± 0.007 (standard) versus 0.019 ± 0.005 (accelerated) (cm(-1) ).

CONCLUSION

Quadruple phased array coil simulations resulted in an optimal acceleration factor of ∼2× independent of imaging resolution. Results advocate undersampled image acceleration to improve accuracy of fractional ventilation measurement with hyperpolarized gas MRI.

Effects of restricted thoracic movement on the regional distribution of ventilation

BACKGROUND

Restricted thoracic movement is often encountered in patients, necessitating mechanical ventilation during surgery or intensive care treatment. High intraabdominal pressure, obesity or thorax rigidity and deformity reduce the chest distensibility and deteriorate the lung function. They render the selection of proper ventilator settings difficult and complicate the weaning process. Electrical impedance tomography (EIT) is currently being proposed as a bedside imaging method for monitoring regional lung ventilation. The objective of our study was to establish whether the effects of decreased chest compliance on regional lung ventilation can be determined by EIT.

METHODS

Ten healthy male volunteers were studied in our pilot study under three conditions: (1) unrestricted breathing and (2) restricted breathing by abdominal and (3) lower rib cage strapping. The subjects were followed during spontaneous tidal breathing in five postures (sitting, supine, prone, left and right side). EIT and spirometry data were acquired in each condition.

RESULTS

The distribution of ventilation in subjects with unrestricted breathing corresponded with the physiologically expected values. In the left and right lateral postures, abdominal and thoracic cage restrictions reduced the ventilation in the dependent lung areas; the non-dependent areas were unaffected. In the prone position, the ventilation of the dependent and non-dependent areas was reduced. The effects of strapping were least pronounced in the supine posture.

CONCLUSIONS

We conclude that EIT is able to measure changes in the regional distribution of ventilation induced by restricted chest movement and has the potential for optimising artificial ventilation in patients with limited chest compliance of different origins.

Effect of airflow rate on vibration response imaging in normal lungs

Background:

Evaluating the effect of airflow rate on amplitude of lung sound energy and regional distribution of lung sounds may assist in the interpretation of computerized acoustic measurements.

Objectives:

The aim of this study was to assess the effect of airflow rate on Vibration Response Imaging (VRI) measurement in healthy lungs.

Methods:

Lung sounds were recorded from 20 healthy adults in the frequency range of 150-250 Hz using 40 piezoelectric sensors positioned on the posterior chest wall. During the recordings, subjects were breathing at airflow rates ranging between 0.3 and 1.7L/s. Online visual feedback was provided using a pneumotach mouthpiece.

Results:

Amplitude of lung sound energy significantly increased with increasing airflow rate (p<0.00001, Friedman test). A strong relationship (R2=0.95) was obtained between amplitude of lung sound energy at peak inspiration and airflow rate raised to the third power. This correlation did not significantly affect normalized lung sound distribution maps at peak inspiration, especially when airflow was higher than 1.0L/s. Acoustic maps obtained at airflow rates below 0.7L/s differed from those recorded above 1.0L/s (p<0.05, Wilcoxon matched-paired signed-ranks test).

Conclusion:

These findings may be of importance when comparing healthy and diseased lungs or when monitoring changes in lung sounds during treatment follow-up.

A Modeling Study of the Effect of Gravity on Airflow Distribution and Particle Deposition in the Lung

Inhalation of particles generated as a result of thermal degradation from fire or smoke, as may occur on spacecraft, is of major health concern to space-faring countries. Knowledge of lung airflow and particle transport under different gravity environments is required to addresses this concern by providing information on particle deposition. Gravity affects deposition of particles in the lung in two ways. First, the airflow distribution among airways is changed in different gravity environments. Second, particle losses by sedimentation are enhanced with increasing gravity. In this study, a model of airflow distribution in the lung that accounts for the influence of gravity was used for a mathematical description of particle deposition in the human lung to calculate lobar, regional, and local deposition of particles in different gravity environments. The lung geometry used in the mathematical model contained five lobes that allowed the assessment of lobar ventilation distribution and variation of particle deposition. At zero gravity, it was predicted that all lobes of the lung expanded and contracted uniformly, independent of body position. Increased gravity in the upright position increased the expansion of the upper lobes and decreased expansion of the lower lobes. Despite a slight increase in predicted deposition of ultrafine particles in the upper lobes with decreasing gravity, deposition of ultrafine particles was generally predicted to be unaffected by gravity. Increased gravity increased predicted deposition of fine and coarse particles in the tracheobronchial region, but that led to a reduction or even elimination of deposition in the alveolar region for coarse particles. The results from this study show that existing mathematical models of particle deposition at 1 G can be extended to different gravity environments by simply correcting for a gravity constant. Controlled studies in astronauts on future space missions are needed to validate these predictions.

Control of pulmonary vascular tone during exercise in health and pulmonary hypertension

Despite the importance of the pulmonary circulation as a determinant of exercise capacity in health and disease, studies into the regulation of pulmonary vascular tone in the healthy lung during exercise are scarce. This review describes the current knowledge of the role of various endogenous vasoactive mechanisms in the control of pulmonary vascular tone at rest and during exercise. Recent studies demonstrate an important role for endothelial factors (NO and endothelin) and neurohumoral factors (noradrenaline, acetylcholine). Moreover, there is evidence that natriuretic peptides, reactive oxygen species and phosphodiesterase activity can influence resting pulmonary vascular tone, but their role in the control of pulmonary vascular tone during exercise remains to be determined. K-channels are purported end-effectors in control of pulmonary vascular tone. However, K(ATP) channels do not contribute to regulation of pulmonary vascular tone, while the role of K(V) and K(Ca) channels at rest and during exercise remains to be determined. Pulmonary hypertension is associated with alterations in pulmonary vascular function and structure, resulting in blunted pulmonary vasodilatation during exercise and impaired exercise capacity. Although there is a paucity of studies pertaining to the regulation of pulmonary vascular tone during exercise in idiopathic pulmonary hypertension, the few studies that have been performed in models of pulmonary hypertension secondary to left ventricular dysfunction suggest altered control of pulmonary vascular tone during exercise. Since the increased pulmonary vascular tone during exercise limits exercise capacity, future studies are needed to investigate the vasomotor mechanisms that are responsible for the blunted exercise-induced pulmonary vasodilatation in pulmonary hypertension.

Distribution of blood flow and ventilation in the lung: gravity is not the only factor

Current textbooks in anaesthesia describe how gravity affects the regional distribution of ventilation and blood flow in the lung, in terms of vertical gradients of pleural pressure and pulmonary vascular pressures. This concept fails to explain some of the clinical features of disturbed lung function. Evidence now suggests that gravity has a less important role in the variation of regional distribution than structural features of the airways and blood vessels. We review more recent studies that used a variety of methods: external radioactive counters, measurements using inhaled and injected particles, and computer tomography scans. These give a higher spatial resolution of regional blood flow and ventilation. The matching between ventilation and blood flow in these small units of lung is considered; the effects of microgravity, increased gravity, and different postures are reviewed, and the application of these findings to conditions such as acute lung injury is discussed. Down to the scale of the acinus, there is considerable heterogeneity in the distribution of both ventilation and blood flow. However, the matching of blood flow with ventilation is well maintained and may result from a common pattern of asymmetric branching of the airways and blood vessels. Disruption of this pattern may explain impaired gas exchange after acute lung injury and explain how the prone position improves gas exchange.

Alterations in endothelial control of the pulmonary circulation in exercising swine with secondary pulmonary hypertension after myocardial infarction

Secondary pulmonary hypertension after myocardial infarction (MI) has been associated with endothelial dysfunction and activation of the endothelin (ET) system. Here, we investigated whether an increased ET-mediated pulmonary vasoconstrictor influence contributes to pulmonary hypertension after MI, and whether this increased ET vasoconstriction is caused by impaired nitric oxide (NO) and prostanoid production. For this purpose, chronically instrumented swine with and without MI ran on a treadmill at 0-4 km h(-1). Mixed ET(A)/ET(B) receptor blockade (tezosentan) was performed in the absence and presence of single or combined inhibition of endothelial NO synthase (eNOS, with N(omega)-nitro-l-arginine) and cyclo-oxygenase (COX, with indometacin). In normal swine, mixed ET(A)/ET(B) blockade decreased pulmonary vascular resistance, but only during exercise. In MI swine, an increased ET-mediated vasoconstrictor influence was observed in the pulmonary circulation both at rest and during exercise. Inhibition of COX resulted in pulmonary vasoconstriction at rest in MI, but not in normal swine; this vasoconstriction in MI swine was normalized by ET(A)/ET(B) receptor blockade. Inhibition of eNOS enhanced the vasodilator response to ET(A)/ET(B) blockade, indicating that NO blunts the pulmonary vasoconstrictor influence of ET. However, this vasodilator response was enhanced to a similar degree in MI and normal swine. In summary, swine with a recent MI are characterized by an exaggerated pulmonary vasoconstrictor influence of ET. This increased ET-mediated pulmonary vasoconstrictor influence is not caused by a loss of NO bioavailability, and is blunted by an increased prostanoid-mediated vasodilatation. In conclusion, an increased ET-mediated vasoconstriction, which does not appear to be the result of loss of endothelial vasodilators, contributes to pulmonary hypertension after MI.

Insufficient ventilation as a cause of impaired pulmonary gas exchange during submaximal exercise

Pulmonary ventilation and gas exchange were determined during prolonged skiing (approximately 76% of V(O2, max); cardiac output=26-27 L min(-1)) using diagonal technique (DIA) for 40 min followed by 10 min of double poling (DPOL) and 10 min of leg skiing (LEG). Exercise caused approximately 2-5% reduction of arterial oxygen saturation Sa(O2). For a given cardiac output and V(O2), DPOL presented higher V(E), lower Pa(CO2) and a more efficient pulmonary gas exchange, revealed by higher PA(O2) and Pa(O2) and lower A-aD(O2). The A-aD(O2) widened 2 mmHg L(-1) of cardiac output increase. However, for a given cardiac output and V(O2), exercise mode had an important influence on pulmonary ventilation and gas exchange. Highly trained cross-country skiers' present about 2 units reduction in Sa(O2) from resting values during submaximal exercise at 76% of V(O2, max). Half of the reduction in saturation is accounted for by the rightward-shift of the oxygen dissociation curve of the haemoglobin. The exercise duration has almost no repercussion on pulmonary gas exchange in these athletes, with the small effect on Sa(O2) associated to the increase in body core temperature.

Position affects distribution of ventilation in the lungs of older people: an experimental study

QUESTION

What is the effect of sitting and side-lying on the distribution of ventilation during tidal breathing in healthy older people?

DESIGN

Randomised, within-participant, experimental study.

PARTICIPANTS

Ten healthy people more than 65 years old.

INTERVENTION

Tidal breathing during sitting and right side-lying.

OUTCOME MEASURES

Distribution of ventilation as a percentage of total counts using Technetium-99m Technegas lung ventilation imaging.

RESULTS

In sitting, the ratio of the distribution of ventilation to apical: middle: basal regions was 1: 3.5: 3.3 in the right lung, and 1: 2.9: 2.3 in the left lung. In right side-lying, 32% (95% CI 22 to 43) more ventilation was distributed to the right lung than to the left lung. The ratio of the distribution of ventilation to apical: middle: basal regions was 1: 2.8: 2.2 in the right lung, and 1: 2.4: 1.9 in the left lung.

CONCLUSIONS

In both sitting and right side-lying, ventilation was distributed more to the middle than to the basal region, which may be related to age-associated changes in the respiratory system.

The value of electrical impedance tomography in assessing the effect of body position and positive airway pressures on regional lung ventilation in spontaneously breathing subjects

OBJECTIVE

Functional electrical impedance tomography (EIT) measures relative impedance changes in lung tissue during tidal breathing and creates images of local ventilation distribution. A novel approach to analyse the effect of body position and positive pressure ventilation on intrapulmonary tidal volume distribution was evaluated in healthy adult subjects.

DESIGN AND SETTING

Prospective experimental study in healthy adult subjects in the intensive care unit at university hospital.

SUBJECTS

Ten healthy male adults.

INTERVENTIONS

Change in body position from supine to prone, left and right lateral during spontaneous breathing and positive pressure support ventilation.

MEASUREMENTS AND RESULTS

EIT measurements and multiple-breath sulphur hexafluoride (SF6) washout were performed. Profiles of average relative impedance change in regional lung areas were calculated. Relative impedance time course analysis and Lissajous figure loop analysis were used to calculate phase angles between dependent or independent lung and total lung (phi). EIT data were compared to SF6 data washout measuring the lung clearance index (LCI). Proposed EIT profiles allowed inter-individual comparison of EIT data and identified areas with reduced regional tidal volume using pressure support ventilation. Phase angle phi of dependent lung in supine position was 11.7+/-1.4 degrees, in prone 5.3+/-0.5 degrees, in right lateral 11.0+/-1.3 degrees and in left lateral position 10.8+/-1.0 degree. LCI increased in supine position from 5.63+/-0.43 to 7.13+/-0.64 in prone position. Measured phi showed inverse relationship to LCI in the four different body positions.

CONCLUSIONS

EIT profiles and phi of functional EIT are new methods to describe regional ventilation distribution with EIT allowing inter-individual comparison.

Effects of viscoelasticity on volume distribution in a two-compartmental model of normal and sick lungs

Among the models describing respiratory mechanics none has been published with the characteristics of two lung compartments including the viscoelastic properties. We used such a model to describe the inspiratory compartmental volume distribution under homogeneous and inhomogeneous conditions. The present mathematical model was tested against actual data and proven accurate. The volume distribution was studied using data from normal subjects and from patients with COPD and ARDS. In a normal lung, changes in viscoelastic constants in one compartment can modify substantially the volume distribution diverting more or less gas to the other compartment. In diseased compartments, the increase of viscoelasticity increased the difference between the compartments and the opposite was true in the less affected compartment. In conclusion, the viscoelastic properties are of paramount importance in determining gas distribution in normal and sick lungs.

Subsecond multisection CT of regional pulmonary ventilation

RATIONALE AND OBJECTIVES

To evaluate the adequacy of multibreath and single-breath stable xenon gas techniques to measure regional ventilation during cardiac-gated, high-speed, multisection imaging, the authors carried out a series of studies using electron-beam computed tomography (CT) and a recently introduced subsecond multisection spiral CT scanner.

MATERIALS AND METHODS

In four anesthetized pigs, the authors implemented single-breath and/or dynamic multibreath wash-in and washout protocols with respiratory-- and cardiac-gated image acquisition. The effects of varying tidal volume and inspiratory flow rate were evaluated independently. Scanning was done at end expiration to avoid artifacts from partial volumed conducting airways, which are filled with inspired gas concentration during inspiration.

RESULTS

A single breath of 100% xenon provides adequate enhancement in the lung parenchyma (mean, 32 HU +/- 1.85 [standard error]) and should not cause unwanted side effects (mean xenon concentration in lung periphery, 21%). The single-breath method is suitable for studies requiring only short periods of apnea. Using the multibreath method, in dependent portions of the lung, there was close agreement between measured changes and predictions based on the xenon calibration data. More than 10 breaths were needed to clear tracer from poorly ventilated areas, and some nondependent regions demonstrated apparently "linear" rather than exponential clearance curves, possibly reflecting longer washout times. Analysis of wash-in and washout curves revealed vertical ventilation gradients and, at higher inspiratory flow rates, redistribution of ventilation to areas of the lung with greater pathway conductance.

CONCLUSION

With careful attention to lung volume and use of cardiac gating, it is now possible to correlate lung structure with function to a degree heretofore not possible.

The effect of breathing exercises with body positioning on regional lung ventilation

This review discusses the distribution of ventilation in the normal adult lung and includes the influence of quiet and deep breathing on regional ventilation. The effects of breathing at low lung volumes; inspiratory flow rate; posture; age; and body weight on ventilation are also described. A selection of breathing exercises are examined with regard to their ability to influence regional ventilation. There is no evidence that breathing control (diaphragmatic breathing exercises) improves regional ventilation to the dependent zones of the lungs. Limited evidence does suggest that thoracic expansion exercises, whereby respiratory muscles are voluntarily contracted to alter regional chest wall expansion, can improve underlying ventilation. However, there remains a paucity of evidence regarding the effects of breathing exercises on regional ventilation.

Effects of exhaustive endurance exercise on pulmonary gas exchange and airway function in women

Seventeen fit women ran to exhaustion (14 +/- 4 min) at a constant speed and grade, reaching 95 +/- 3% of maximal O(2) consumption. Pre- and postexercise lung function, including airway resistance [total respiratory resistance (Rrs)] across a range of oscillation frequencies, was measured, and, on a separate day, airway reactivity was assessed via methacholine challenge. Arterial O(2) saturation decreased from 97.6 +/- 0.5% at rest to 95.1 +/- 1.9% at 1 min and to 92.5 +/- 2.6% at exhaustion. Alveolar-arterial O(2) difference (A-aDO(2)) widened to 27 +/- 7 Torr after 1 min and was maintained at this level until exhaustion. Arterial PO(2) (Pa(O(2))) fell to 80 +/- 8 Torr at 1 min and then increased to 86 +/- 9 Torr at exhaustion. This increase in Pa(O(2)) over the exercise duration occurred due to a hyperventilation-induced increase in alveolar PO(2) in the presence of a constant A-aDO(2). Arterial O(2) saturation fell with time because of increasing temperature (+2.6 +/- 0.5 degrees C) and progressive metabolic acidosis (arterial pH: 7.39 +/- 0.04 at 1 min to 7.26 +/- 0.07 at exhaustion). Plasma histamine increased throughout exercise but was inversely correlated with the fall in Pa(O(2)) at end exercise. Neither pre- nor postexercise Rrs, frequency dependence of Rrs, nor diffusing capacity for CO correlated with the exercise A-aDO(2) or Pa(O(2)). Although several subjects had a positive or borderline hyperresponsiveness to methacholine, this reactivity did not correlate with exercise-induced changes in Rrs or exercise-induced arterial hypoxemia. In conclusion, regardless of the degree of exercise-induced arterial hypoxemia at the onset of high-intensity exercise, prolonging exercise to exhaustion had no further deleterious effects on A-aDO(2), and the degree of gas exchange impairment was not related to individual differences in small or large airway function or reactivity.

Regional deposition and retention of particles in shallow, inhaled boluses: effect of lung volume

The regional deposition of particles in boluses delivered to shallow lung depths and their subsequent retention in the airways may depend on the lung volume at which the boluses are delivered. To evaluate the effect of end-inspiratory lung volume on aerosol bolus delivery, we had healthy subjects inhale radiolabeled, monodisperse aerosol (99mTc-iron oxide, 3.5-microm mass median aerodynamic diameter) boluses (40 ml) to a volumetric front depth of 70 ml into the lung at lung volumes of 50, 70, and 85% of total lung capacity (TLC) end inhalation. By gamma camera analysis, we found significantly greater deposition in the left (L) vs. right (R) lungs at the 70 and 85% TLC end inhalation; ratio of deposition in L to R lung, normalized to L-to-R ratio of lung volume (mean L/R), was 1.60 +/- 0.45 (SD) and 1. 96 +/- 0.72, respectively (P < 0.001 for comparison to 1.0) for posterior images. However, at 50% TLC, L/R was 1.23 +/- 0.37, not significantly different from 1.0. These data suggest that the L and R lungs may be expanding nonuniformly at higher lung volumes. On the other hand, subsequent retention of deposited particles at 2 and 24 h postdeposition was independent of L/R at the various lung volumes. Thus asymmetric bolus ventilation for these very shallow boluses does not lead to significant increases in peripheral alveolar deposition. These data may prove useful for 1) designing aerosol delivery techniques to target bronchial airways and 2) understanding airway retention of inhaled particles.

Bronchial airway deposition and retention of particles in inhaled boluses: effect of anatomic dead space

The fractional deposition of particles in boluses delivered to shallow lung depths and their subsequent retention in the airways may depend on the relative volume and size of an individual's airways. To evaluate the effect of variable anatomic dead space (ADS) on aerosol bolus delivery we had healthy subjects inhale radiolabeled, monodisperse aerosol (99mTc-iron oxide, 3.5 micron mean mondispersed aerosol diameter) boluses (40 ml) to a volumetric front depth of 70 ml into the lung at a lung volume of 70% total lung capacity end inhalation. By using filter techniques, aerosol photometry, and gamma camera analysis, we estimated the fraction of the inhaled boluses deposited in intrathoracic airways (IDF). ADS by single-breath N2 washout was also measured from 70% total lung capacity. Results showed that among all subjects IDF was variable (range = 0.04-0.43, coefficient of variation = 0.54) and increased with decreasing ADS (r = -0.76, P = 0.001, n = 16). We found significantly greater deposition in the left (L) vs. right (R) lungs; mean L/R (ratio of deposition in L lung to R lung, normalized to ratio of L-to-R lung volume) was 1.58 +/- 0.42 (SD; P < 0.001 for comparison with 1.0). Retention of deposited particles at 2 h was independent of ADS or IDF. There was significant retention of particles at 24 h postdeposition (0.27 +/- 0.05) and slow clearance of these particles continued through 48 h postdeposition. Finally, analysis of central-to-peripheral ratios of initial deposition and 24-h-retention gamma-camera images suggest significant retention of insoluble particles in large bronchial airways at 24 h postdeposition (i.e., 24 h central-to-peripheral ratio = 1.40 +/- 0. 44 and 1.82 +/- 0.54 in the R and L lung, respectively; P < 0.02 for comparison with 1.0). These data may prove useful for 1) designing aerosol delivery techniques to target bronchial airways and 2) understanding airway retention of inhaled particles.

Regional ventilation in statically and dynamically hyperinflated dogs

Using the parenchymal marker technique in normal anesthetized dogs, we compared the dynamics of regional lung expansion between two ventilation strategies designed to increase mean thoracic volume. Dynamic hyperinflation (DH was produced by ventilating the lungs at a rate of 50 breaths/min and with a duty cycle of 0.5. Static hyperinflation (SH) was produced through the application of extrinsic positive end-expiratory pressure while the lungs were ventilated at a rate of 15 breaths/min and with a duty cycle of 0.15. Regional tidal volume (VT,r), regional functional residual volume, and the time delay between regional expansion and the flow signal at the common airway were computed for up to 100 regions/lobe in 5 animals. Ventilation strategy had no effect on the overall variance of VT,r within lobes. Although the VT,r measured during SH correlated with VT,r measured during DH, the average correlation coefficient was only 0.69. Ventilation rate-related differences in VT,r and regional functional residual capacity varied with the regional time delay in ways qualitatively consistent with parallel inhomogeneity of unit time constants. However, a large component of frequency-dependent behavior remains unexplained by established mechanisms. We conclude that DH and SH should not be considered equivalent lung unit recruitment strategies.

Distribution of inspired gas to each lung in the anaesthetised horse and influence of body shape

The distribution of inspired gas to each lung, time constants of the lungs and parameters of gas exchange were studied in 2 groups of horses (mean bwt 606 kg), anaesthetised using thiopentone and chloral hydrate and breathing room air. One group (n = 4) had a downward curved abdominal contour (round-bellied) and the other group (n = 4) had an upward curved abdominal contour (flat-bellied). An equal distribution of inspired gas between the lungs existed in both groups in dorsal recumbency. Flat-bellied horses maintained this equal distribution in lateral recumbency whereas in round-bellied horses an uneven distribution of tidal volume (VT) developed. The percentage of (VT) distributed to the dependent lung was 23% and 38% for left and right lateral recumbency respectively. The distribution of VT agreed with the ratio of time constants of the lungs in flat-bellied horses but differed markedly from this ratio in round-bellied horses suggesting that, in the latter, factors other than compliance and resistance play a role in distribution of ventilation. Round-bellied horses had a lower PaO2 and a larger (A-a)PaO2 than flat-bellied horses in all body positions. The results are compatible with the known hypothesis that pressure exerted by abdominal contents on the dependent lung and diaphragm is an important factor in ventilation/perfusion mismatch of the anaesthetised horse.

Implications of a biphasic two-compartment model of constant flow ventilation for the clinical setting

PURPOSE

To investigate the theoretical effects of changing frequency (f), duty cycle (D), or end-inspiratory pause length on the distribution of ventilation and compartmental pressure in a heterogeneous, two compartment pulmonary model inflated by constant flow.

METHODS

Differential equations governing compartmental volume changes were derived and solved. Validation was conducted in a mechanical lung analogue with two mechanically independent compartments. Model predictions were then generated over wide ranges of f, D, or end-inspiratory pause.

RESULTS

Disparity of compartmental end-expiratory pressure was identified as the primary mechanism by which changes in f, D, or pause alter the distribution of ventilation. Distribution of peak pressures was less sensitive to such changes. Compartmental ventilation was much less uniform than compartmental peak pressure. Ventilation could not be made entirely uniform by changes of f, D, or pause within the usual clinical range.

CONCLUSIONS

In a linear, two compartment model of the respiratory system, disparity of compartmental end-expiratory pressures is the primary mechanism by which changes of f, D, or pause alter the distribution of ventilation during inflation with constant flow. Ventilation is less evenly distributed than peak alveolar pressure, and there are limits to the beneficial effects on the distribution of ventilation to be gained from manipulations of machine settings.

Factors affecting distribution of airflow in a human tracheobronchial cast

Air velocity was measured at end airways of hollow replicate casts of the human tracheobronchial tree in order to determine the flow distribution within casts extending to 3 mm diameter airways. Measurements were made by hot-wire anemometry for constant inspiratory flow rates of 7.5, 15, 30 and 60 L.min-1. Average flow distribution among the lung lobes was as follows: right upper, 18.5%; right middle, 9.2%; right lower, 32.3%; left upper, 15.7%; and left lower, 24.3%. An empirical model derived from the experimental flow distribution data demonstrated the effect of various morphometric parameters of the hollow cast on the distribution of airflow. Airway cross-sectional area, branching angle and total path-length were found to have the greatest influence. As the tracheal flow rate decreased from 60 to 7.5 L.min-1, the influence of branching angle was reduced, while total path-length became more influential. These results provide evidence for the transition of flow regimes within the TB tree within normal physiological flow ranges.

Estimates of mean alveolar PCO2 during steady-state exercise in man: a theoretical study

The partial pressure of carbon dioxide in arterial blood is an important operator in the control of breathing, by actions on peripheral and central chemoreceptors. In experiments on man we must often assume that lung alveolar PCO2 equals arterial PCO2 and obtain estimates of the former derived from measurements in expired gas sampled at the mouth. This paper explores the potential errors of such estimates, which are magnified during exercise. We used a published model of the cardiopulmonary system to simulate various levels of exercise up to 300 W. We tested three methods of estimating mean alveolar PCO2 (PACO2) against the true value derived from a time average of the within-breath oscillation in steady-state exercise. We used both sinusoidal and square-wave ventilatory flow wave forms. Over the range 33-133 W end-tidal PCO2 (P(et)CO2) overestimated PACO2 progressively with increasing workload, by about 4 mmHg at 133 W with normal respiratory rate for that load. PCO2 by a graphical approximation technique (PgCO2; "graphical method") underestimated PACO2 by 1-2 mmHg. PCO2 from an experimentally obtained empirical equation (PnjCO2; "empirical method") overestimated PACO2 by 0.5-1.0 mmHg. Graphical and empirical methods were insensitive to alterations in cardiac output or respiratory rate. End-tidal PCO2 was markedly affected by respiratory rate during exercise, the overestimate of PACO2 increasing if respiratory rate was slowed. An increase in anatomical dead space with exercise tends to decrease the error in P(et)CO2 and increase the error in the graphical method. Changes in the proportion of each breath taken up by inspiration make no important difference, and changes in functional residual capacity, while important in principle, are too small to have any major effect on the estimates. Changes in overall alveolar ventilation which alter steady-state PACO2 over a range of 30-50 mmHg have no important effect. At heavy work loads (200-300 W), P(et)CO2 grossly overestimates by 6-9 mmHg. The graphical method progressively underestimates, by about 5 mmHg at 300 W. A simulated CO2 response (the relation between ventilation and increasing PCO2) performed at 100 W suggests that a response slope close to the true one can be obtained by using any of the three methods. The graphical method gave results closest to the true absolute values. Either graphical or empirical methods should be satisfactory for detecting experimentally produced changes in PACO2 during steady-state exercise, to make comparisons between different steady-state exercise loads, and to assess CO2 response in exercise.(ABSTRACT TRUNCATED AT 400 WORDS)

Pulmonary flow resistance

In the past it has been generally assumed that pulmonary flow resistance (RL) increases with increasing flow and decreases with increasing lung volume. Recent work indicates that RL decreases with increasing flow, at least up to flow rates 3-4 times greater than those at rest, and increases progressively with increasing lung volume. This behaviour results mainly from dynamic pressure dissipations within the pulmonary tissues due to viscoelastic phenomena. In fact, during resting breathing the contribution of the latter to RL is more important than that of airway resistance.

Quantitative analysis of radioaerosol inhalation and perfusion scintigraphy in dogs

A method was developed for the analysis of 99mTc MAA perfusion and 99mTc phytate colloid aerosol inhalation distribution patterns. Scintigraphic images were compared, based on the activity of corresponding picture elements (pixels). The possible mismatching in a pixel between both distributions was expressed in terms of a regional mismatching (common to a whole region) and an additional intraregional mismatching at the individual pixel level. Parameters characterizing the degree of regional and intraregional mismatching were introduced. The method was applied to 16 anesthetized healthy dogs in which a cranial-to-caudal gradient in regional mismatching was found.

Diffusion-dependent contribution to the slope of the alveolar plateau

Two healthy subjects performed single breath tests, the inspired gas containing 90% O2, 5% He and 5% SF6. The slope of the alveolar plateau was computed for N2, HE and SF6. The following experimental conditions were considered variable: (1) preinspiratory lung volume (PILV) with inspired volume (VT) equal to 1 L, (2) VT with PILV equal to functional residual capacity (FRC) with and without 10 sec of breath-hold (BH) time, (3) VT with PILV = FRC + 1 L, (4) flow with VT = 1 L and PILV = FRC with and without 10 sec end inspiration BH and (5) BH time with VT = 1 L and PILV = FRC. The slope dependence on the different variables was compared with simulations performed with two multibranch point models of the human acinus with different asymmetries. The model simulations give a coherent picture of all the experimental observations. The present work gives support to previous analyses which suggest that inter-dependence of transport by convection and diffusion in the periphery of the lung is a major component of the slope of the alveolar plateau.

Lung function following upper sleeve lobectomy for bronchogenic carcinoma

Eight patients who underwent upper sleeve lobectomy and six who underwent upper simple lobectomy for lung cancer were studied. The two groups were matched for age and preoperative lung function as assessed by standard spirometry. Post-operative lung function studies, including measurements of regional ventilation (Vr) and perfusion (Qr) by 133 Xenon technique showed that: 1) two weeks after surgery, forced expiratory volume at 1 s was more reduced after simple than after sleeve lobectomy, but in both groups Vr and its vertical gradient were similarly reduced in the operated lung compared to the contralateral; 2) one year after sleeve lobectomy, the vertical gradient of Vr tended to disappear in both lungs while Vr and Vr/Qr of the operated side increased significantly. These results indicate that early after surgery lung function may be less impaired after sleeve than simple lobectomy; however, long-term changes of regional lung function may occur after sleeve lobectomy resulting into a high Vr/Qr ratio in the operated lung.

Efficiency of ventilation in neonatal pulmonary maladaptation

Lung physiology was studied in sixteen infants with pulmonary maladaptation (PMA) during the course of the disease and after clinical recovery. A sensitive nitrogen washout method was used. During the disease the infants showed reduced ventilatory efficiency and increased dead space. Total ventilation increased simultaneously, while alveolar ventilation was maintained. The majority of the infants showed greater functional residual capacity during the disease than after clinical recovery. The results suggest that gas mixing efficiency is impaired in infants with PMA and that this might be due to effects on the small airway function in the lungs.

Physiological aspects of intermittent positive pressure ventilation

The mechanical properties of the lungs and chest wall dictate the relationship between tidal volume, flow rate and airway pressure developed during intermittent positive pressure ventilation (IPPV). The increase in intrathoracic pressures associated with IPPV has consequences for the intrapulmonary distribution of ventilation and perfusion (hence gas exchange), cardiac output and regional blood flows. Barotrauma is a potential hazard. IPPV also affects the homeostatic mechanisms that keep the air spaces dry. Strategies to maximise the benefits and minimise the side effects of IPPV include positive end-expiratory pressure, intermittent mandatory ventilation, differential lung ventilation and high frequency ventilation. Understanding the physiological effects of IPPV and associated therapies allows a rational approach to the adjustment of ventilation against pulmonary, cardiovascular and systemic responses so as to optimise gas exchange and peripheral oxygen delivery.

Regional alveolar pressure during periodic flow. Dual manifestations of gas inertia

We measured pressure excursions at the airway opening and at the alveoli (PA) as well as measured the regional distribution of PA during forced oscillations of six excised dog lungs while frequency (f[2-32 Hz]), tidal volume (VT [5-80 ml]), and mean transpulmonary pressure (PL [25, 10, and 6 cm H2O]) were varied. PA's were measured in four alveolar capsules glued to the pleura of different lobes. The apex-to-base ratio of PA's was used as an index of the distribution of dynamic lung distension. At low f, there was slight preferential distension of the lung base which was independent of VT, but at higher f, preferential distension of the lung apex was found when VT's were small, whereas preferential distension of the lung base was found when VT's approached or exceeded dead space. These VT-related changes in distribution at high frequencies seem to depend upon the branching geometry of the central airways and the relative importance of convective momentum flux vs. unsteady inertia of gas residing therein, which, in this study, we showed to be proportional to the ratio VT/VD*, where VD* is an index of dead space. Furthermore, they imply substantial alteration in the distribution of ventilation during high frequency ventilation as f, VT, and PL vary. The data also indicate that alveolar and airway opening pressure costs per unit flow delivered at the airway opening exhibit weakly nonlinear behavior and that resonant amplification of PA's, which has been described previously for the case of very small VT's, persists but is damped as VT's approach dead space values.

Gas exchange in tidally ventilated and non-steadily perfused lung model

We studied the effect of cyclic lung perfusion - fast cycle in synchrony with heart beats and slow cycle in synchrony with ventilation - on gas exchange in a lung model. There was almost no effect in the fast cycle. In a homogeneous single-lung unit, arterial PO2 increased, and the (A - a)DO2 decreased (by approximately 0.5 Torr), as the amplitude of the slow cyclic lung perfusion (TIP) increased. The calculated (A - a)DO2 and (a - A)DCO2 were negative. Maximal PaO2 was found when peak lung perfusion was delayed with respect to ventilation by 0.2 of a cycle. In a non-homogeneous nine-unit lung, cyclic lung perfusion caused an increase in PaO2 and a decrease in (A - a)DO2 by 2 Torr as compared to steady perfusion. No apparent negative (A - a)DO2 was found, but apparent negative (a - A)DCO2 was calculated at no pulmonary shunt and also with 5% shunt. The correlation of cyclic lung perfusion to the reduced (A - a)DO2 in dense-gas breathing - where large swings of pleural pressure are expected - and its effect on the diffusion capacity of the lung are discussed. Non-steady perfusion of the lung as caused by ventilatory movements expanded our understanding of gas exchange and shed some light on a few controversial experimental findings, such as the negative (a - A)DCO2, the decreased (A - a)DO2 while breathing dense gas, and the effects of gas density on diffusion capacity of the lung.

Inspiratory flow effects on mechanically ventilated patients: lung volume, inhomogeneity, and arterial oxygenation

Changes in the inspiratory flow rate of mechanically ventilated patients can affect arterial oxygenation. Although the mechanism producing this alteration is not certain, one possible mechanism is a change in ventilation inhomogeneity. This study was performed to determine if the inspiratory flow setting would affect ventilation inhomogeneity in patients who have minimal or no lung disease, but who require mechanical ventilation after cardiopulmonary bypass surgery. When inspiratory flows were doubled, PaO2 increased and FRC fell. However, no associated change in ventilation inhomogeneity was detected. It is concluded that inspiratory flow rate can affect arterial oxygenation of subjects without severe obstructive pulmonary disease through mechanisms other than altering ventilation inhomogeneity, such as changes in cardiac output or in distribution of perfusion.

Variations of regional lung function in acute respiratory failure and during anaesthesia

Acute respiratory failure and anaesthesia impede ventilation of dependent lung units and perfusion of non-dependent ones, creating considerable ventilation-perfusion (V/Q) mismatch. General PEEP can improve V/Q but it cannot restore it to normal. To improve matching, ventilation must be distributed in proportion to regional blood flow. This can be accomplished by (1) placing the subject in the lateral position, (2) ventilating each lung in proportion to its blood flow (differential ventilation), and (3) applying PEEP solely to the dependent lung to ensure even distribution of inspired gas within that lung (selective PEEP). Differential ventilation with equal distribution of the tidal volume between the lungs and a selective PEEP of 10 cm H2O to the dependent lung resulted in equal distribution of perfusion between the lungs in anaesthetized healthy subjects, suggesting "optimum" V/Q matching. Using this ventilator setting as a rule of thumb in patients with acute, severe, bilateral lung disease, arterial oxygen tension was improved by an average of 45% compared with that during general PEEP, with no reduction in cardiac output. It is concluded that differential ventilation with selective PEEP can offer considerable improvement in gas exchange in acute, bilateral lung disease. However, long-term studies are required before a final evaluation can be made.

Differential ventilation and selective PEEP during anaesthesia in the lateral decubitus posture

The potential of differential ventilation (DV) with selective positive end-expiratory pressure (PEEP) has been tested versus conventional ventilation with and without general PEEP. Gas exchange and central haemodynamics were studied in 15 subjects with no clinical or radiological signs of pulmonary disease. The rationale of the method was to ensure ventilation of the well-perfused dependent lung and to counteract airway closure within that lung. The subjects were intubated with a double-lumen catheter prior to scheduled abdominal surgery. During general anaesthesia in the lateral posture, they were given DV. The mean inspired oxygen fraction was 0.32. Fifty per cent ("even" tidal volume (VT) distribution) or 70% ("inverted" VT distribution) of the inspired volume was administered to the dependent lung. Two synchronized ventilators were used. In eight subjects DV was also combined with PEEP applied solely to the dependent lung (selective PEEP). The major findings were that DV with even VT distribution reduced venous admixture by 26% (P less than 0.05) and the alveolo-arterial oxygen tension gradient (P(A-a)o2) by 30% (P less than 0.05) in comparison with conventional ventilation in the lateral position. The addition of selective PEEP further reduced the P(A-a)o2 by 13%. P(A-a)o2 was consequently 43% lower than during conventional ventilation without PEEP in the lateral posture (P less than 0.01). Selective PEEP also had less impact on cardiac output than general PEEP (P less than 0.05). It is concluded that DV with even distribution of VT and selective PEEP can reduce the P(A-a)o2 in anaesthetized lung-healthy subjects in the lateral position.

Effect of posture on inter-regional distribution of pulmonary ventilation in man

Regional ventilation per unit alveolar volume (V/VA) and regional lung expansion (FRCR/TLCR) were measured in twelve normal male human subjects in seated, supine, lateral decubitus and prone postures using a gamma camera and inhalation of the radioactive gases 81Krm (half-life 13 sec) and 85Krm (half-life 4.4 h). FRCR/TLCR decreased from superior to inferior in all postures except prone where it was uniform; V/VA increased from superior to inferior except in the prone position where it was uniform. In the horizontal axis FRCR/TLCR and V/VA were uniformly distributed except for cranial to caudal gradients (with lower values caudally) in supine and lateral decubitus postures. In the prone posture V/VA tended to be higher in caudal lung zones.

Cardiogenic mixing in the pulmonary conducting airways of man?

The increase in dispersion of a bolus of helium (He) or sulfur hexafluoride (SF6) was used as a direct, non-invasive measure of pulmonary gas mixing in the conducting airways of one female and two male subjects. Mixing was compared for matched respiratory maneuvers at rest and during bicycle ergometer exercise at 35-50% VO2 max (tidal volume of 2 L, inspiratory flow rate greater than or equal to 1.5 L/s, mean expiratory flow rate of 2.8 L/s, and bolus penetrations of 30, 90, 150 and 180 ml). No enhancement of mixing occurred when the heart rate was increased 53% by bicycle exercise. The results suggest that cardiogenic mixing in the upper and central airways is unresponsive to normal changes in the hear rate.