Altered thoracic gas compression contributes to improvement in spirometry with lung volume reduction surgery

BACKGROUND

Thoracic gas compression (TGC) exerts a negative effect on forced expiratory flow. Lung resistance, effort during a forced expiratory manoeuvre, and absolute lung volume influence TGC. Lung volume reduction surgery (LVRS) reduces lung resistance and absolute lung volume. LVRS may therefore reduce TGC, and such a reduction might explain in part the improvement in forced expiratory flow with the surgery. A study was conducted to determine the effect of LVRS on TGC and the extent to which reduced TGC contributed to an improvement in forced expiratory volume in 1 second (FEV1) following LVRS.

METHODS

The effect of LVRS on TGC was studied using prospectively collected lung mechanics data from 27 subjects with severe emphysema. Several parameters including FEV1, expiratory and inspiratory lung resistance (Rle and Rli), and lung volumes were measured at baseline and 6 months after surgery. Effort during the forced manoeuvre was measured using transpulmonary pressure. A novel method was used to estimate FEV1 corrected for the effect of TGC.

RESULTS

At baseline the FEV1 corrected for gas compression (NFEV1) was significantly higher than FEV1 (p<0.0001). FEV1 increased significantly from baseline (p<0.005) while NFEV1 did not change following surgery (p>0.15). TGC decreased significantly with LVRS (p<0.05). Rle and maximum transpulmonary pressure (TP(peak)) during the forced manoeuvre significantly predicted the reduction in TGC following the surgery (Rle: p<0.01; TP(peak): p<0.0001; adjusted R2 = 0.68). The improvement in FEV1 was associated with the reduction in TGC after surgery (p<0.0001, adjusted R2 = 0.58).

CONCLUSIONS

LVRS decreased TGC by improving expiratory flow limitation. In turn, the reduction in TGC decreased its negative effect on expiratory flow and therefore explained, in part, the improvement in FEV1 with LVRS in this cohort.

Regional expiratory flow limitation studied with Technegas in asthma

Regional expiratory flow limitation (EFL) may occur during tidal breathing without being detected by measurements of flow at the mouth. We tested this hypothesis by using Technegas to reveal sites of EFL. A first study (study 1) was undertaken to determine whether deposition of Technegas during tidal breathing reveals the occurrence of regional EFL in induced bronchoconstriction. Time-activity curves of Technegas inhaled during 12 tidal breaths were measured in four asthmatic subjects at control conditions and after exposure to inhaled methacholine at a dose sufficient to abolish expiratory flow reserve near functional residual capacity. A second study (study 2) was conducted in seven asthmatic subjects at control and after three increasing doses of methacholine to compare the pattern of Technegas deposition in the lung with the occurrence of EFL. The latter was assessed at the mouth by comparing tidal with forced expiratory flow or with the flow generated on application of a negative pressure. Study 1 documented enhanced and spotty deposition of Technegas in the central lung regions with increasing radioactivity during tidal expiration. This is consistent with increased impaction of Technegas on the airway wall downstream from the flow-limiting segment. Study 2 showed that both methods based on analysis of flow at the mouth failed to detect EFL at the time spotty deposition of Technegas occurred. We conclude that regional EFL occurs asynchronously across the lung and that methods based on mouth flow measurements are insensitive to it.

Respiratory control during independent lung ventilation

We describe the case of a lung transplant patient with primary graft failure and an emphysematous native lung, who displayed different respiratory rates between the transplanted lung and the native lung. Inflation of the native lung delayed the next inspiratory effort relative to inflation of the denervated transplanted lung. Synchronous inflation of both lungs required more pressure in each lung than when that lung was inflated with the contralateral lung near functional residual capacity, suggesting the two lungs compete for space within the thoracic cavity.

Effects of smooth muscle activation on axial mechanical properties of excised canine bronchi

This study tested the hypothesis that airway smooth muscle (ASM) activation produces an airway active axial force (AAAF). Bronchi (n = 10) immersed in a tissue bath containing 95% O2-5% CO2-equilibrated Krebs solution were subjected to passive axial lengthening and shortening at 0-20 cmH2O of transmural pressure. ASM was relaxed with isoproterenol and activated with methacholine. Axial tensile (epsilonx), transverse compressive (epsilony), and shear strains (epsilonxy) were computed from the displacements of four markers placed onto the specimen's surface. The AAAF was estimated by subtracting the control axial force (AF) values at a given epsilonx from those obtained after methacholine. epsilonx-AF relationships were curvilinear, with maximum epsilonx being approached at approximately 15 g of AF. The epsilony decreased during bronchial lengthening. Cholinergic stimulation produced 1) a decrease of both epsilonx and epsilony at a given AF relative to control, indicating ASM shortening, and 2) an AAAF that increased with increasing epsilonx and transmural pressure. A portion of the work of expanding the lungs is required to lengthen the airways; therefore, an AAAF would increase lung elastance and recoil.

Respiratory dynamics during laughter

Lung and chest wall mechanics were studied during fits of laughter in 11 normal subjects. Laughing was naturally induced by showing clips of the funniest scenes from a movie by Roberto Benigni. Chest wall volume was measured by using a three-dimensional optoelectronic plethysmography and was partitioned into upper thorax, lower thorax, and abdominal compartments. Esophageal (Pes) and gastric (Pga) pressures were measured in seven subjects. All fits of laughter were characterized by a sudden occurrence of repetitive expiratory efforts at an average frequency of 4.6 +/- 1.1 Hz, which led to a final drop in functional residual capacity (FRC) by 1.55 +/- 0.40 liter (P < 0.001). All compartments similarly contributed to the decrease of lung volumes. The average duration of the fits of laughter was 3.7 +/- 2.2 s. Most of the events were associated with sudden increase in Pes well beyond the critical pressure necessary to generate maximum expiratory flow at a given lung volume. Pga increased more than Pes at the end of the expiratory efforts by an average of 27 +/- 7 cmH2O. Transdiaphragmatic pressure (Pdi) at FRC and at 10% and 20% control forced vital capacity below FRC was significantly higher than Pdi at the same absolute lung volumes during a relaxed maneuver at rest (P < 0.001). We conclude that fits of laughter consistently lead to sudden and substantial decrease in lung volume in all respiratory compartments and remarkable dynamic compression of the airways. Further mechanical stress would have applied to all the organs located in the thoracic cavity if the diaphragm had not actively prevented part of the increase in abdominal pressure from being transmitted to the chest wall cavity.

Modeling the kinematics of the canine midcostal diaphragm

The hypotheses that the chest wall insertion (CW) is displaced laterally during inspiration and that this displacement is essential in maintaining muscle curvature of the costal diaphragmatic muscle fibers were tested. With the use of data from three dogs, caudal, lateral, and ventral displacements of CW during both quiet, spontaneous inspiration and during inspiratory efforts against an occluded airway were observed and recorded. We have developed a kinematic model of the diaphragm that incorporates these displacements. This model describes the motions of the muscle fibers and central tendon; the displacements of the midplane, muscle-tendon junction (MTJ), CW, and center of the muscle fiber-central tendon arcs are modeled as functions of muscle fiber length. In the model, the center of the fiber arcs and MTJ both move caudally parallel to the midplane during inspiration, whereas CW moves both caudally and laterally. The observed lateral displacement of CW and the observed caudal displacement of MTJ, as functions of muscle fiber length, both approximate well the theoretical displacements that would be necessary to maintain curvature of the fiber arcs. In confirming our hypotheses, we have found that lateral displacement of CW is a mechanism by which changes in the shape of the costal diaphragm, as described by its curvature, are limited.

Shape and tension distribution of the passive rat diaphragm

We developed an in vitro preparation to investigate shape and stress distribution in the intact rat diaphragm. Our hypothesis was that the diaphragm is anisotropic with smaller compliance in transverse fiber direction than along fibers, and therefore shape change may be small. After the animals were killed (8 rats), the entire diaphragm was excised and fixed into a mold at the insertions. Oxygenated Krebs-Ringer solution was circulated under the diaphragm and perfused over its surface. A total of 20-23 small markers were sutured on the diaphragm surface. At transdiaphragmatic pressure (P(di)) of 3-15 cmH(2)O, curvature was smaller in transverse direction than along fibers. Using finite element analysis we computed membrane tension. At P(di) of 15 cmH(2)O, tension in central tendon was larger than muscle. In costal region maximum principal tension (sigma(1)) is essentially along the fibers and ranged from 6-10 g/cm. Minimum principal tension (sigma(2)) was 0. 3-4 g/cm. In central tendon, sigma(1) was 10-15 g/cm, compared with 4-10 g/cm for sigma(2). The diaphragm was considerably stiffer in transverse fiber direction than along the fibers.

Inferences on force transmission from muscle fiber architecture of the canine diaphragm

Functional properties of the diaphragm are mediated by muscle structure. Modeling of force transmission necessitates a precise knowledge of muscle fiber architecture. Because the diaphragm experiences loads both along and transverse to the long axes of its muscle fibers in vivo, the mechanism of force transmission may be more complex than in other skeletal muscles that are loaded uniaxially along the muscle fibers. Using a combination of fiber microdissections and histological and morphological methods, we determined regional muscle fiber architecture and measured the shape of the cell membrane of single fibers isolated from diaphragm muscles from 11 mongrel dogs. We found that muscle fibers were either spanning fibers (SPF), running uninterrupted between central tendon (CT) and chest wall (CW), or were non-spanning fibers (NSF) that ended within the muscle fascicle. NSF accounted for the majority of fibers in the midcostal, dorsal costal, and lateral crural regions but were only 25-41% of fibers in the sternal region. In the midcostal and dorsal costal regions, only approximately 1% of the NSF terminated within the fascicle at both ends; the lateral crural region contained no such fibers. We measured fiber length, tapered length, fiber diameters along fiber length, and the taper angle for 271 fibers. The lateral crural region had the longest mean length of SPF, which is equivalent to the mean muscle length, followed by the costal and sternal regions. For the midcostal and crural regions, the percentage of tapered length of NSF was 45.9 +/- 5.3 and 40.6 +/- 7.5, respectively. The taper angle was approximately 0.15 degrees for both, and, therefore, the shear component of force was approximately 380 times greater than the tensile component. When the diaphragm is submaximally activated, as during normal breathing and maximal inspiratory efforts, muscle forces could be transmitted to the cell membrane and to the extracellular intramuscular connective tissue by shear linkage, presumably via structural transmembrane proteins.

Biaxial constitutive relations for the passive canine diaphragm

Samples of the muscular sheet excised from the midcostal region of dog diaphragms were subjected to biaxial loading. That is, stresses in the direction of the muscle fibers and in the direction perpendicular to the fibers in the plane of the sheet were measured at different combinations of strains in the two directions. Stress-strain relations were obtained by fitting equations to these data. In the direction of the muscle fibers, for strains up to 0.7, stress is a modestly nonlinear function of strain and ranges up to approximately 60 g/cm. In the direction perpendicular to the fibers, the sheet is stiffer and more strongly nonlinear. At a strain in the perpendicular direction of approximately 0.35, stress increases abruptly. The stress-strain relation in the muscle direction is consistent with observations of passive muscle shortening in vivo. However, the stiffness in the perpendicular direction is not high enough to explain the observation that strains in the perpendicular direction in vivo are nearly zero. We conclude that, in the passive diaphragm in vivo, stress in the direction perpendicular to the muscle fibers is small.

Mechanism of reduced maximal expiratory flow with aging

To investigate the determinants of maximal expiratory flow (MEF) with aging, 17 younger (7 men and 10 women, 39 +/- 4 yr, mean +/- SD) and 19 older (11 men and 8 women, 69 +/- 3 yr) subjects with normal pulmonary function were studied. For further comparison, we also studied 10 middle-aged men with normal lung function (54 +/- 6 yr) and 15 middle-aged men (54 +/- 7 yr) with mild chronic airflow limitation (CAL; i.e., forced expiratory volume in 1 s/forced vital capacity = 63 +/- 8%). MEF, static lung elastic recoil pressure (Pst), and the minimal pressure for maximal flow (Pcrit) were determined in a pressure-compensated, volume-displacement body plethysmograph. Values were compared at 60, 70, and 80% of total lung capacity. In the older subjects, decreases in MEF (P < 0.01) and Pcrit (P < 0.05), compared with the younger subjects, were explained mainly by loss of Pst (P < 0.05). In the CAL subjects, MEF and Pcrit were lower (P < 0.05) than in the older subjects, but Pst was similar. Thus decreases in MEF and Pcrit were greater than could be explained by the loss of Pst and appeared to be related to increased upstream resistance. These data indicate that the loss of lung recoil explains the decrease in MEF with aging subjects, but not in the mild CAL patients that we studied.

Shape of the canine diaphragm

In an earlier study (Angelillo M, Boriek AM, Rodarte JR, and Wilson TA. J Appl Physiol 83: 1486-1491, 1997), we proposed a mathematical theory for the structure and shape of the diaphragm. Muscle bundles were assumed to lie on lines that are simultaneously geodesics and lines of principal curvature of the diaphragm surface, and the class of surfaces that are formed by line elements that are both geodesics and lines of principal curvature was described. Here we present data on the shape of the canine diaphragm that were obtained by the radiopaque marker technique, and we describe a surface that fits the data and satisfies the requirements of the theory. The costal and crural diaphragms are fit by cyclides with radii of 3.7 and 2.3 cm, respectively. In addition, the theory is extended to include the description of a joint between cyclides, and the observed properties of the joint between the costal and crural diaphragms at the dorsal end of the costal diaphragm match those required by the theory.

Breathing during exercise in subjects with mild-to-moderate airflow obstruction: effects of physical training

In this study we explored the effects of physical training on the response of the respiratory system to exercise. Eight subjects with irreversible mild-to-moderate airflow obstruction [forced expiratory volume in 1 s of 85 +/- 14 (SD) % of predicted and ratio of forced expiratory volume in 1 s to forced vital capacity of 68 +/- 5%] and six normal subjects with similar anthropometric characteristics underwent a 2-mo physical training period on a cycle ergometer three times a week for 31 min at an intensity of approximately 80% of maximum heart rate. At this work intensity, tidal expiratory flow exceeded maximal flow at control functional residual capacity [FRC; expiratory flow limitation (EFL)] in the obstructed but not in the normal subjects. An incremental maximum exercise test was performed on a cycle ergometer before and after training. Training improved exercise capacity in all subjects, as documented by a significant increase in maximum work rate in both groups (P < 0.001). In the obstructed subjects at the same level of ventilation at high workloads, FRC was greater after than before training, and this was associated with an increase in breathing frequency and a tendency to decrease tidal volume. In contrast, in the normal subjects at the same level of ventilation at high workloads, FRC was lower after than before training, so that tidal volume increased and breathing frequency decreased. These findings suggest that adaptation to breathing under EFL conditions does not occur during exercise in humans, in that obstructed subjects tend to increase FRC during exercise after experiencing EFL during a 2-mo strenuous physical training period.

Lung elastic recoil during breathing at increased lung volume

During dynamic hyperinflation with induced bronchoconstriction, there is a reduction in lung elastic recoil at constant lung volume (R. Pellegrino, O. Wilson, G. Jenouri, and J. R. Rodarte. J. Appl. Physiol. 81: 964-975, 1996). In the present study, lung elastic recoil at control end inspiration was measured in normal subjects in a volume displacement plethysmograph before and after voluntary increases in mean lung volume, which were achieved by one tidal volume increase in functional residual capacity (FRC) with constant tidal volume and by doubling tidal volume with constant FRC. Lung elastic recoil at control end inspiration was significantly decreased by approximately 10% within four breaths of increasing FRC. When tidal volume was doubled, the decrease in computed lung recoil at control end inspiration was not significant. Because voluntary increases of lung volume should not produce airway closure, we conclude that stress relaxation was responsible for the decrease in lung recoil.

Airway responsiveness to methacholine: effects of deep inhalations and airway inflammation

We determined the dose-response curves to inhaled methacholine (MCh) in 16 asthmatic and 8 healthy subjects with prohibition of deep inhalations (DIs) and with 5 DIs taken after each MCh dose. Flow was measured on partial expiratory flow-volume curves at an absolute lung volume (plethysmographically determined) equal to 25% of control forced vital capacity (FVC). Airway inflammation was assessed in asthmatic subjects by analysis of induced sputum. Even when DIs were prohibited, the dose of MCh causing a 50% decrease in forced partial flow at 25% of control FVC (PD(50)MCh) was lower in asthmatic than in healthy subjects (P < 0.0001). In healthy but not in asthmatic subjects, repeated DIs significantly decreased the maximum response to MCh [from 90 +/- 4 to 62 +/- 8 (SD) % of control, P < 0.001], increased PD(50)MCh (P < 0.005), without affecting the dose causing 50% of maximal response. In asthmatic subjects, neither PD(50)MCh when DIs were prohibited nor changes in PD(50)MCh induced by DIs were significantly correlated with inflammatory cell numbers or percentages in sputum. We conclude that 1) even when DIs are prohibited, the responsiveness to MCh is greater in asthmatic than in healthy subjects; 2) repeated DIs reduce airway responsiveness in healthy but not in asthmatic subjects; and 3) neither airway hyperresponsiveness nor the inability of DIs to relax constricted airways in asthmatic subjects is related to the presence of inflammatory cells in the airways.

Ratio of active to passive muscle shortening in the canine diaphragm

Active and passive shortening of muscle bundles in the canine diaphragm were measured with the objective of testing a consequence of the minimal-work hypothesis: namely, that the ratio of active to passive shortening is the same for all active muscles. Lengths of six muscle bundles in the costal diaphragm and two muscle bundles in the crural diaphragm of each of four bred-for-research beagle dogs were measured by the radiopaque marker technique during the following maneuvers: a passive deflation maneuver from total lung capacity to functional residual capacity, quiet breathing, and forceful inspiratory efforts against an occluded airway at different lung volumes. Shortening per liter increase in lung volume was, on average, 70% greater during quiet breathing than during passive inflation in the prone posture and 40% greater in the supine posture. For the prone posture, the ratio of active to passive shortening was larger in the ventral and midcostal diaphragm than at the dorsal end of the costal diaphragm. For both postures, active shortening during quiet breathing was poorly correlated with passive shortening. However, shortening during forceful inspiratory efforts was highly correlated with passive shortening. The average ratios of active to passive shortening were 1.23 +/- 0.02 and 1.32 +/- 0.03 for the prone and supine postures, respectively. These data, taken together with the data reported in the companion paper (T. A. Wilson, M. Angelillo, A. Legrand, and A. De Troyer, J. Appl. Physiol. 87: 554-560, 1999), support the hypothesis that, during forceful inspiratory efforts, the inspiratory muscles drive the chest wall along the minimal-work trajectory.

Mechanical advantage of the canine diaphragm

The mechanical advantage (mu) of a respiratory muscle is defined as the respiratory pressure generated per unit muscle mass and per unit active stress. The value of mu can be obtained by measuring the change in the length of the muscle during inflation of the passive lung and chest wall. We report values of mu for the muscles of the canine diaphragm that were obtained by measuring the lengths of the muscles during a passive quasistatic vital capacity maneuver. Radiopaque markers were attached along six muscle bundles of the costal and two muscle bundles of the crural left hemidiaphragms of four bred-for-research beagle dogs. The three-dimensional locations of the markers were obtained from biplane video-fluoroscopic images taken at four volumes during a passive relaxation maneuver from total lung capacity to functional residual capacity in the prone and supine postures. Muscle lengths were determined as a function of lung volume, and from these data, values of mu were obtained. Values of mu are fairly uniform around the ventral midcostal and crural diaphragm but significantly lower at the dorsal end of the costal diaphragm. The average values of mu are -0.35 +/- 0.18 and -0.27 +/- 0.16 cmH2O. g-1. kg-1. cm-2 in the prone and supine dog, respectively. These values are 1. 5-2 times larger than the largest values of mu of the intercostal muscles in the supine dog. From these data we estimate that during spontaneous breathing the diaphragm contributes approximately 40% of inspiratory pressure in the prone posture and approximately 30% in the supine posture. Passive shortening, and hence mu, in the upper one-third of inspiratory capacity is less than one-half of that at lower lung volume. The lower mu is attributed primarily to a lower abdominal compliance at high lung volume.

Assessing the reversibility of airway obstruction

STUDY OBJECTIVE

To determine whether changes of partial expiratory flow-volume curve (PEFV) and inspiratory capacity (IC) detect functional responses to bronchodilator in patients who do not meet the FEV1 criteria for reversibility of airway obstruction.

DESIGN/METHODS

The effects of salbutamol (200 microg by metered-dose inhaler) on lung function were examined in 50 patients with asthma and 28 patients with COPD. Measurements evaluated were FEV1, forced expiratory flow at 30% of control FVC from maximal expiratory flow-volume curve (Vm30), forced expiratory flow at 30% of control FVC from PEFV (Vp30), and IC. On a separate occasion, a representative sample of 26 subjects inhaled placebo to determine the 95% confidence limits (CLs) of each of the parameters.

RESULTS

A percent and absolute increment of FEV1 above the upper CL was recorded in 28 patients. Of these, 26 had a percent and absolute increase of Vp30, 21 of Vm30, 9 of FVC, and 11 of IC above the 95% CL. Of the 50 patients who did not have an increase in FEV1 above the 95% CL, 25 had a percent and absolute increase in Vp30, 15 of Vm30, 3 of FVC, and 13 of IC above the 95% CL. On average, the percent and absolute increase Vp30 above the 95% CL significantly identified more responders than every other parameter.

CONCLUSION

Increases in maximal flow detected by PEFV and/or changes in IC may be substantially obscured by the effects of inspiration to total lung capacity required for the measurement of FEV1 in patients with chronic bronchoconstriction. Decreases in functional residual capacity (FRC) manifested by an increase of IC occur because, in patients whose FRC is dynamically determined, bronchodilatation that increases maximal flow in the tidal breathing range allows patients to breathe at lower lung volumes. Changes of FEV1 frequently fail to detect significant functional response to bronchodilators in patients with chronic airflow obstruction.

Measurement of pulmonary resistance and dynamic compliance with airway obstruction

We compared four algorithms by using least squares regression for determination of pulmonary resistance and dynamic elastance in subjects with emphysema, normal subjects, and subjects with asthma before and after bronchoconstriction. The four methods evaluated include 1) a single resistance and elastance, 2) separate resistances and elastances for each half breath, 3) separate inspiratory and expiratory resistances with a single elastance, and 4) separate inspiratory and expiratory resistances, an expiratory volume interaction term, and a single elastance. All methods gave comparable results in normal and asthmatic subjects. We found expiratory resistance was larger than inspiratory resistance in normal and asthmatic subjects during control conditions, but inspiratory resistance was higher than expiratory resistance in subjects who experienced severe bronchoconstriction in response to methacholine. In subjects who are flow limited, method 2 gives a higher inspiratory resistance than would be computed by assuming that the elastic pressure-volume curve passes through the zero-flow points. Methods 1 and 3 overestimate dynamic elastance and inspiratory resistance. Method 4 appears to identify flow limitation and dynamic hyperinflation and gives a good measure of inspiratory resistance and dynamic elastance.

Breathing by double-lung recipients during exercise: response to expiratory threshold loading

Ventilation during exercise is near-normal in double-lung transplant recipients despite lung denervation. We tested the hypothesis that denervation effects might be unmasked during exercise by exposing these patients to an expiratory load. Eight double-lung recipients and nine intact control subjects were exercised to exhaustion. Ergometer work increased 20 Watt every 2 min; expiratory threshold loading (4 cm H2O) was imposed for five to six breaths at each exercise level; ventilation and O2 consumption were measured. Transplant recipients and control subjects increased ventilation similarly for comparable fractions of maximal work. At maximal exercise, transplant recipients achieved lower work (62 versus 155 W; p < 0.001) and O2 consumption (0.88 versus 2.26 L/min; p < 0.001) than control subjects, with proportional reductions in tidal volume (1.6 versus 2.6 L; p < 0.05) and ventilation (38 versus 79 L/min; p < 0.01). Threshold loading decreased expiratory flow, breathing frequency, and minute ventilation in both groups (p < 0.05). Unlike control subjects, transplant recipients also slowed inspiratory flow (p < 0.05) and prolonged inspiration (p < 0.01), exaggerating the fall in breathing frequency and ventilation (p < 0.01). We conclude that afferent information from pulmonary receptors modulates inspiration during expiratory loading; bilateral denervation disrupts these pathways, causing double-lung recipients to inspire more slowly.

Muscle fiber architecture of the dog diaphragm

Previous measurements of muscle thickness and length ratio of costal diaphragm insertions in the dog (A. M. Boriek and J. R. Rodarte. J. Appl. Physiol. 77: 2065-2070, 1994) suggested, but did not prove, discontinuous muscle fiber architecture. We examined diaphragmatic muscle fiber architecture using morphological and histochemical methods. In 15 mongrel dogs, transverse sections along the length of the muscle fibers were analyzed morphometrically at x20, by using the BioQuant System IV software. We measured fiber diameters, cross-sectional fiber shapes, and cross-sectional area distributions of fibers. We also determined numbers of muscle fibers per cross-sectional area and ratio of connective tissue to muscle fibers along a course of the muscle from near the chest wall (CW) to near the central tendon (CT) for midcostal left and right hemidiaphragms, as well as ventral, middle, and dorsal regions of the left costal hemidiaphragm. In six other mongrel dogs, the macroscopic distribution of neuromuscular junctions (NMJ) on thoracic and abdominal diaphragm surfaces was determined by staining the intact diaphragmatic muscle for acetylcholinesterase activity. The average major diameter of muscle fibers was significantly smaller, and the number of fibers was significantly larger midspan between CT and CW than near the insertions. The ratio of connective tissues to muscle fibers was largest at CW compared with other regions along the length of the muscle. The diaphragm is transversely crossed by multiple scattered NMJ bands with fairly regular intervals offset in adjacent strips. Muscle fascicles traverse two to five NMJ, consistent with fibers that do not span the entire fascicle from CT to CW. These results suggest that the diaphragm has a discontinuous fiber architecture in which contractile forces may be transmitted among the muscle fibers through the connective tissue adjacent to the fibers.

Tolerance of volunteers to cyclosporine A-dilauroylphosphatidylcholine liposome aerosol

Cyclosporine A (CsA) in liposomes of dilauroylphosphatidylcholine (DLPC), containing 118 micrograms of CsA/L of aerosol with a particle size of 1.6 to 1.7 micron diameter, was inhaled by 10 nonsmoking, normal volunteers each for 45 min. Aerosol was administered through an Aerotech II nebulizer (CIS-US, Inc., Bedford, MA) mouthpiece. Eight of the 10 volunteers had tracheal irritation and intermittent coughing following exposure. FEV1 and FVC values were mildly reduced, but returned to normal in 1 h. Blood chemical and hematologic values were unchanged at any time point after as opposed to before inhalation. Nine of the 10 volunteers later inhaled DLPC only, administered through the nebulizer mouthpiece. There was no change in FEV1 or FVC values, and there was no coughing or tracheal irritation. Subsequently, five of the volunteers who had previously had respiratory reactions inhaled CsA-DLPC liposome aerosol for 45-min, but through a mouth-only face mask. There was no tracheal irritation, coughing, or changes in spirometric measures. Blood concentrations of CsA at 15 min after the 45-min inhalation with a face mask averaged 83 +/- 42 ng/ml (mean +/- SD). At 24 h after treatment, CsA was undetectable in blood of the initial 10 volunteers. These studies indicate that CsA-DLPC liposome aerosol can be safely explored as a treatment for patients with moderately severe asthma.

Theory of diaphragm structure and shape

The muscle bundles of the diaphragm form a curved sheet that extends from the chest wall to the central tendon. Each muscle bundle exerts a force in the direction of its curvature; the magnitude of this force is proportional to the curvature of the bundle. The contribution of this force to transdiaphragmatic pressure is maximal if the direction of bundle curvature is orthogonal to the surface and the curvature is maximal. That is, the contribution of muscle tension to transdiaphragmatic pressure is maximal if the muscle bundles lie along lines that are both geodesics and lines of maximal principal curvature of the surface. A theory of diaphragm shape is developed from the assumption that all muscle bundles have these optimal properties. The class of surfaces that are formed of line elements that are both geodescis and lines of principal curvature is described. This class is restricted. The lines that form the surface must lie in planes, and all lines must have the same shape. In addition, the orientation of the lines is restricted. An example of this class that is similar to the shape of the canine diaphragm is described, and the stress distribution in this example is analyzed.

Kinematics and mechanics of midcostal diaphragm of dog

Radiopaque markers were attached to the peritoneal surface of three neighboring muscle bundles in the midcostal diaphragm of four dogs, and the locations of the markers were tracked by biplanar video fluoroscopy during quiet spontaneous breathing and during inspiratory efforts against an occluded airway at three lung volumes from functional residual capacity to total lung capacity in both the prone and supine postures. Length and curvature of the muscle bundles were determined from the data on marker location. Muscle lengths for the inspiratory states, as a fraction of length at functional residual capacity, ranged from 0.89 +/- 0.04 at end inspiration during spontaneous breathing down to 0.68 +/- 0.07 during inspiratory efforts at total lung capacity. The muscle bundles were found to have the shape of circular arcs, with the three bundles forming a section of a right circular cylinder. With increasing lung volume and diaphragm displacement, the circular arcs rotate around the line of insertion on the chest wall, the arcs shorten, but the radius of curvature remains nearly constant. Maximal transdiaphragmatic pressure was calculated from muscle curvature and maximal tension-length data from the literature. The calculated maximal transdiaphragmatic pressure-length curve agrees well with the data of Road et al. (J. Appl. Physiol. 60: 63-67, 1986).

The relationship between maximal expiratory flow and increases of maximal exercise capacity with exercise training

We previously reported that patients with mild to moderate airflow limitation have a lower exercise capacity than age-matched controls with normal lung function, but the mechanism of this reduction remains unclear (1). Although the reduced exercise capacity appeared consistent with deconditioning, the patients had altered breathing mechanics during exercise, which raised the possibility that the reduced exercise capacity and the altered breathing mechanics may have been causally related. Reversal of reduced exercise capacity by an adequate exercise training program is generally accepted as evidence of deconditioning as the cause of the reduced exercise capacity. We studied 11 asymptomatic volunteer subjects (58 +/- 8 yr of age [mean +/- SD]) selected to have a range of lung function (FEV1 from 61 to 114% predicted, with a mean of 90 +/- 18% predicted). Only one subject had an FEV1 of less than 70% predicted. Gas exchange and lung mechanics were measured during both steady-state and maximal exercise before and after training for 30 min/d on 3 d/wk for 10 wk, beginning at the steady-state workload previously determined to be the maximum steady-state exercise level that subjects could sustain for 30 min without exceeding 90% of their observed maximal heart rate (HR). The training workload was increased if the subject's HR decreased during the training period. After 10 wk, subjects performed another steady-state exercise test at the initial pretraining level, and another maximal exercise test. HR decreased significantly between the first and second steady-state exercise tests (p < 0.05), and maximal oxygen uptake (VO2max) and ventilation increased significantly (p < 0.05) during the incremental test, indicating a training effect. However, the training effect did not occur in all subjects. Relationships between exercise parameters and lung function were examined by regression against FEV1 expressed as percent predicted. There was a significant positive correlation between VO2max percent predicted and FEV1 percent predicted (p < 0.02), and a negative correlation between FEV1 and end-expiratory lung volume (EELV) at maximal exercise (p < 0.03). There was no significant correlation between FEV1 and maximal HR achieved during exercise; moreover, all subjects achieved a maximal HR in excess of 80% predicted, suggesting a cardiovascular limitation to exercise. These data do not support the hypothesis that the lower initial VO2max in the subjects with a reduced FEV1 was due to deconditioning. Although increased EELV at maximal exercise, reduced VO2max and a reduced VO2max response with training are all statistically associated with a reduced FEV1, there is no direct evidence of causality.

Vital capacities in acute and chronic airway obstruction: dependence on flow and volume histories

The aim of this study was to investigate whether measurements of vital capacity (VC) are affected by the direction of the manoeuvre (inspiratory vs expiratory) and by the rate of expiratory flow. The study was performed on 25 individuals with chronic airway obstruction (CAO) and a forced expiratory volume in one second (FEV1) (expressed in standardized residuals (SR)) of -2.0+/-1.4 SD (CAO group), and 10 asthmatic subjects with methacholine (MCh)-induced bronchoconstriction (FEV1 -23+/-1.02 SR) (MCh group). VCs were measured during fast inspiration following both slow (FIVCse) and forced (FIVCfe) expiration from end-tidal inspiration to residual volume (RV), and during slow (EVC) or forced (FVC) expiration from total lung capacity (TLC). In the CAO group, FVC was the smallest volume (3.75+/-1.03 L) and significantly different from the other three estimates of VC; FIVCse (4.03+/-0.91 L) was the largest volume and significantly different from FVC and FIVCfe (3.83+/-0.98 L). In the MCh group, FVC (4.16+/-0.94 L) and EVC (4.19+/-0.89 L) were the largest volumes, although only the difference between FVC and FIVCfe (3.76+/-0.81 L) reached statistical significance. These data suggest that both flow and volume histories contribute to decreased vital capacities during bronchoconstriction. However, whereas increasing expiratory flow always tends to decrease vital capacity, the volume history of full inflation has different effects in chronic and acute bronchoconstriction, probably due to different effects on airway calibre. These results stress the importance of using standardized manoeuvres in order to obtain comparable values of vital capacity.

Effects of transverse fiber stiffness and central tendon on displacement and shape of a simple diaphragm model

Our previous experimental results (A. M. Boriek, S. Lui, and J. R. Rodarte. J. Appl. Physiol. 75: 527-533, 1993 and A. M. Boriek, T. A. Wilson, and J. R. Rodarte. J. Appl. Physiol. 76: 223-229, 1994) showed that 1) costal diaphragm shape is similar at functional residual capacity and end inspiration regardless of whether the diaphragm muscle shortens actively (increased tension) or passively (decreased tension); 2) diaphragmatic muscle length changes minimally in the direction transverse to the muscle fibers, suggesting the diaphragm may be inextensible in that direction; and 3) the central tendon is not stretched by physiological stresses. A two-dimensional orthotropic material has two different stiffnesses in orthogonal directions. In the plane tangent to the muscle surface, these directions are along the fibers and transverse to the fibers. We wondered whether orthotropic material properties in the muscular region of the diaphragm and inextensibility of the central tendon might contribute to the constancy of diaphragm shape. Therefore, in the present study, we examined the effects of stiffness transverse to muscle fibers and inextensibility of the central tendon on diaphragmatic displacement and shape. Finite element hemispherical models of the diaphragm were developed by using pressurized isotropic and orthotropic membranes with a wide range of stiffness ratios. We also tested heterogeneous models, in which the muscle sheet was an orthotropic material, having transverse fiber stiffness greater than that along the fibers, with the central tendon being an inextensible isotropic cap. These models revealed that increased transverse stiffness limits the shape change of the diaphragm. Furthermore, an inextensible cap simulating the central tendon dramatically limits the change in shape as well as the membrane displacement in response to pressure. These findings provide a plausible mechanism by which the diaphragm maintains similar shapes despite different physiological loads. This study suggests that changes of diaphragm shape are restricted because the central tendon is essentially inextensible and stiffness in the direction transverse to the muscle fibers is greater than stiffness along the fibers.

Zone of apposition in the passive diaphragm of the dog

We determined the regional area of the diaphragmatic zone of apposition (ZAP) as well as the regional craniocaudal extent of the ZAP (ZAPht) of the passive diaphragm in six paralyzed anesthetized beagle dogs (8-12 kg) at residual lung volume (RV), functional residual capacity (FRC), FRC + 0.25 and FRC + 0.5 inspiratory capacity, and total lung capacity (TLC) in prone and supine postures. To identify the caudal boundary of the ZAP, 17 lead markers (1 mm) were sutured to the abdominal side of the costal and crural diaphragms around the diaphragm insertion on the chest wall. Two weeks later, the dogs' caudal thoraces were scanned by the use of the dynamic spatial reconstructor (DSR), a prototype fast volumetric X-ray computer tomographic scanner, developed at the Mayo Clinic. The three-dimensional spatial coordinates of the markers were identified (+/- 1.4 mm), and the cranial boundary of the ZAP was determined from 30-40 1.4-mm-thick sagittal and coronal slices in each DSR image. We interpolated the DSR data to find the position of the cranial and caudal boundaries of the ZAP every 5 degrees around the thorax and computed the distribution of regional variation of area of the ZAP and ZAPht as well as the total area of ZAP. The ZAPht and area of ZAP increased as lung volume decreased and were largest near the lateral extremes of the rib cage. We measured the surface area of the rib cage cephaled to the ZAP (AL) in both postures in another six beagle dogs (12-16 kg) of similar stature, scanned previously in the DSR. We estimated the entire rib cage surface area (Arc = AZAP + AL). The AZAP as a percentage of Arc increased more than threefold as lung volume decreased from TLC to RV, from approximately 9 to 29% of Arc.

Lung mechanics during induced bronchoconstriction

To elucidate differences in lung mechanics, we investigated the relative changes of partial forced expiratory flows at 50 and 30% of vital capacity, pulmonary resistance (RL), dynamic elastance (Edyn), and the effects of a deep inhalation (DI) on maximal flows, Edyn, and RL in eight asthmatic and eight normal individuals during bronchial challenges with methacholine, histamine, and ATP. RL was partitioned into inspiratory and expiratory resistance. Different constrictor agents did not induce specific patterns of response. For a given decrement of flow at 50 and 30% vital capacity, RL increased significantly more in normal than in asthmatic individuals. The ratio of inspiratory to expiratory RL was always < 1 at baseline but became > 1 in the majority of asthmatic and normal individuals when RL exceeded 12.2 +/- 0.9 cmH2O.1-1.s, suggesting that tidal inspiration may have induced transient bronchodilation in more constricted subjects. In asthmatic individuals, DI had a significantly smaller effect on flow but not on RL compared with normal individuals. The recovery of RL and Edyn after DI was faster than Edyn for both normal and asthmatic individuals. These findings are consistent with the idea that asthmatic individuals have a stronger peripheral response to agonists than normal individuals.

Inferences on passive diaphragm mechanics from gross anatomy

The diaphragm is a relatively thin curved structure that is categorized in mechanics as a membrane. Tension in the membrane is given by the product of muscle thickness and stress parallel to the fiber bundles. If all muscle fibers were cylindrical and extended from origin to insertion, the ratio of thickness near the chest wall (CW) to thickness near the central tendon (CT) would vary inversely with the ratio of CW to CT perimeters. In freshly excised diaphragms of 36 mongrel dogs, the ratios of the perimeters (CT/CW) in the right and left costal diaphragm were 0.63 +/- 0.04 and 0.62 +/- 0.04, respectively. The means of the ratio of thickness near CW to that near CT in the right and left costal regions were 0.96 +/- 0.07 and 0.95 +/- 0.05, respectively, consistent with a nearly constant relationship between costal diaphragm membrane tension and muscle stress in the direction of the fibers. In the crural diaphragm, the average ratio of the perimeters of the insertions on CT to CW was 1.16 +/- 0.10. The average ratio of thickness of crural CW to CT was 1.25 +/- 0.11. The discrepancy between the perimeter ratio and thickness ratio in the costal diaphragm is incompatible with the muscle consisting of uniform fibers extending from CW to CT. Our data suggest that muscle fibers are either in series with a smaller number along the smaller perimeter or that they terminate by tapering within the muscle bundle. Both arrangements are consistent with previous anatomic studies (Gordon et al. J. Morphol. 201: 131-143, 1989). Having a nonuniform number of fibers mechanically in series is compatible with uniform stress in the fibers if the membrane is sufficiently curved as in a domed structure.

Finite-element analysis of stress in the canine diaphragm

Stress in the diaphragm, transdiaphragmatic pressure, and diaphragm shape are interrelated by a balance of forces. Using precise in vivo measurements of diaphragm shape and transdiaphragmatic pressure distribution in combination with finite-element analysis (ANSYS), we determined the direction and magnitude of stress in the passive diaphragm at relaxation volume. Lead spheres sutured along muscle bundles identified muscle bundle location and orientation in vivo. The x, y, and z coordinates of the lead spheres and entire surface of the diaphragm, excluding the zone of apposition, were determined to within 1.4 mm. Thin shell elements were used to construct a finite-element model of the diaphragm with a 2.1- to 4.2-mm internodal spacing. The diaphragm was assumed to have a uniform thickness of 2.5 mm, and magnitude and direction of the principal stresses were computed. The results show that 1) diaphragm stress is nonuniform and anisotropic (i.e., varies both with location on diaphragm surface and direction examined), 2) largest stress (sigma 1) is aligned with muscle bundles and is two to four times larger than sigma 2 (perpendicular to sigma 1 in diaphragm plane), and 3) stress along the muscle bundles is larger in vivo under conditions of biaxial stress than at same length in vitro under uniaxial stress. Although diaphragm stress and tension have often been assumed to be uniform, our finding that stress is oriented primarily along the muscle fibers should be considered in future models of the diaphragm.(ABSTRACT TRUNCATED AT 250 WORDS)

Displacements and strains in the costal diaphragm of the dog

Radiopaque markers were attached at 1- to 2-cm intervals along three nearby muscle bundles to cover rectangular regions of the mid-costal diaphragms of seven dogs. The markers were tracked by biplane video fluoroscopy during spontaneous breathing (SB), mechanical ventilation with the same tidal volume (MV), and at inflation to total lung capacity (TLC) in the prone and supine positions. The three-dimensional positions of the markers at functional residual capacity (FRC), at end inspiration during SB and MV, and at TLC were determined, and the strains in the plane of the diaphragm relative to FRC were calculated. The principal strains were found to lie nearly along the muscle bundle direction and perpendicular to it. The principal strains along the muscle bundles, which describe muscle shortening, were uniform among the three bundles and uniform along the bundle for MV. For SB, in the prone and supine positions, shortening was approximately 30% greater in the middle of the bundle than near the central tendon and chest wall. Although the tidal volumes were the same for SB and MV, the shortening was larger for SB. The strains perpendicular to the bundle direction were not significantly different from zero. It appears that, for the loads that occur during tidal breathing, the diaphragm is inextensible in the direction perpendicular to the muscle direction. There is a very small displacement of the costal diaphragm at its insertion on the chest wall. The displacement at the central tendon is primarily a result of muscle shortening and rotation of the arc of the muscle around its insertion on the chest wall.

Expiratory airflow limitation and hyperinflation during methacholine-induced bronchoconstriction

To investigate the role of airflow limitation on the increase of end-expiratory lung volume (EELV) during bronchoconstriction, nine stable asthmatic subjects and seven healthy subjects were challenged with inhaled methacholine (MCh). Changes in airway caliber were assessed by using forced expiratory volume in 1 s, partial forced expiratory flow at 50% of control forced vital capacity, and specific airway conductance. To detect airflow limitation, tidal flow-volume curves were superimposed on partial forced flow-volume curves at absolute lung volume. The electromyogram of the diaphragm was recorded by surface electrodes in four asthmatic and four healthy subjects, and the electrical diaphragmatic activity (DIA) during expiration was expressed as a percentage of the duration of expiratory time. In 10 subjects (9 asthmatic and 1 healthy) the partial forced expiratory flow recorded after some MCh dose impinged on tidal expiratory flow recorded before MCh. When this occurred it was associated with an increase in EELV by 0.54 +/- 0.07 (SE) liter (P < 0.001), which was larger than that occurring when lower MCh doses (0.11 +/- 0.04 liter, P < 0.05) were used, and with a moderate increase in DIA of 15 +/- 2.5% (P < 0.01). Six healthy subjects did not increase EELV after MCh despite a significant degree of bronchoconstriction; in these subjects tidal expiratory flow never impinged on forced expiratory flow, and DIA never increased. These results suggest that hyperinflation during MCh-induced bronchoconstriction is triggered by dynamic compression of the airways and is associated with moderate increase of DIA during expiration.

Costal diaphragm curvature in the dog

The curvature of the midcostal region of the diaphragm in seven dogs was determined at functional residual capacity (FRC) and end inspiration during spontaneous breathing and mechanical ventilation and at total lung capacity in the prone and supine positions. Metallic markers were attached to muscle fibers on the abdominal surface of the diaphragm, and the dog was allowed to recover from surgery. The three-dimensional positions of the markers were determined by biplane videofluoroscopy. A quadratic surface was fit to the bead positions. The principal axes of the quadratic surface lie nearly along and perpendicular to the muscle fibers. In both the supine and prone positions, the values of the principal curvatures were similar at FRC and end inspiration during spontaneous breathing, when muscle tension and transdiaphragmatic pressure both increase with increasing lung volume, and during mechanical ventilation and passive inflation to total lung capacity, when both decrease relative to their magnitude at FRC. No abrupt change of curvature, which might be expected at the edge of the zone of apposition, was apparent. The curvature along the muscle fiber was 0.35 +/- 0.07 cm-1; the curvature perpendicular to the muscle fiber was much smaller, 0.06 +/- 0.01 cm-1. The costal region of the diaphragm displaces and shortens as lung volume increases, but its shape, as described by its curvatures, does not change substantially.

Expiratory flow limitation and regulation of end-expiratory lung volume during exercise

To investigate the impact of expiratory flow limitation (FL) on breathing pattern and end-expiratory lung volume (EELV), we imposed a small expiratory threshold load for a few breaths during exercise in nine volunteers (29-62 yr): six were healthy and three had mild-to-moderate airflow obstruction (67-71% predicted forced expiratory volume in 1 s). Six subjects showed evidence of FL, i.e., tidal expiratory flow impinging on maximal forced expiratory flow, at one or more exercise levels. Whenever an expiratory threshold load was imposed, mean expiratory flow decreased (P < 0.02) in association with an increased expiratory time (TE; P < 0.05). When the load was imposed during non-FL conditions, TE increased less than expiratory flow decreased and EELV tended to increase. In contrast, during FL, with the load, TE increased more than expiratory flow decreased, subjects did not achieve maximal expiratory flow until a lower volume, and EELV decreased (P < 0.001). Under both FL and no-FL conditions, unloading reversed the changes associated with loading. These data indicate that the increase in EELV during exercise is linked to the occurrence of FL. We suggest that compression of airways downstream from the flow-limiting segment may elicit a reflex mechanism that influences breathing pattern by terminating expiration prematurely, thus increasing EELV.

Estimation of ventilatory capacity during submaximal exercise

There is presently no precise way to determine ventilatory capacity for a given individual during exercise; however, this information would be helpful in evaluating ventilatory reserve during exercise. Using schematic representations of maximal expiratory flow-volume curves and individual maximal expiratory flow-volume curves from four subjects, we describe a technique for estimating ventilatory capacity. In these subjects, we measured maximal expiratory flow-volume loops at rest and tidal flow-volume loops and inspiratory capacity (IC) during submaximal cycle ergometry. We also compared minute ventilation (VE) during submaximal exercise with calculated ventilatory maxima (VEmaxCal) and with maximal voluntary ventilation (MVV) to estimate ventilatory reserve. Using the schematic flow-volume curves, we demonstrated the theoretical effect of maximal expiratory flow and lung volume on ventilatory capacity and breathing pattern. In the subjects, we observed that the estimation of ventilatory reserve with use of VE/VEmaxCal was most helpful in indicating when subjects were approaching maximal expiratory flow over a large portion of tidal volume, especially at submaximal exercise levels where VE/VEmaxCal and VE/MVV differed the most. These data suggest that this technique may be useful in estimating ventilatory capacity, which could then be used to evaluate ventilatory reserve during exercise.

Changes in functional residual capacity and regional diaphragm lengths after upper abdominal surgery in anesthetized dogs

The respiratory performance of the diaphragm may be altered by changes in mechanical or neural factors, or both, induced by upper abdominal surgery. We conducted this study to examine the effects of upper abdominal surgery on postoperative respiratory function. We studied resting lengths of four diaphragm regions, three in the costal and one in the crural diaphragm, with biplane video-roentgenography in six dogs immediately after upper abdominal surgery and up to 30 days postoperatively. Functional residual capacity was 16.7% smaller immediately after surgery compared with values obtained in the same animals after 30 days. Simultaneously measured resting lengths of each of the diaphragm regions immediately after surgery were longer, on average by 8.3%, than 30 days postoperatively. During the postoperative course, resting diaphragm lengths gradually and uniformly decreased as functional residual capacity increased. Phrenic nerve stimulation in four other dogs immediately after identical surgery resulted in large diaphragm shortening (from 42% to 55%), indicating that neither the diaphragm nor phrenic nerves were injured by the surgical manipulation. We hypothesize that respiratory dysfunction after upper abdominal surgery may be, at least in part, attributed to a decreased central drive for breathing caused by activation of the afferent limb of an inhibitory reflex owing to stretching of the diaphragm.

Exercise capacity and breathing mechanics in patients with airflow limitation

To investigate the impact of expiratory airflow limitation on ventilation during exercise, we studied six control subjects with normal lung function (FEV1/FVC = 79 +/- 6%) and eight patients with borderline-to-mild airflow limitation (FEV1/FVC = 68 +/- 4%) during cycle ergometry. VO2, HR, and VE/MVV were not different between the control subjects or patients during maximal or submaximal exercise. In contrast, five of the eight patients achieved maximal expiratory flow over a large portion (37%) of their tidal volume (VT) during submaximal exercise, whereas none of the control subjects achieved maximal expiratory flow. To estimate the fraction of expiratory capacity used by the control subjects and the patients, we calculated a mechanical ventilatory maximum (VEmaxCal) for each level of exercise using the individual's VT, end-expiratory lung volume (EELV), and maximal expiratory flow-volume curve. The patients used a greater fraction of their VEmaxCal at each level of submaximal exercise (P less than 0.03). Despite the flow limitation during submaximal exercise, EELV was similar between the control subjects and patients. In conclusion, even patients with borderline-to-mild airflow limitation achieve maximal expiratory flow during submaximal exercise and these restrictions are not reflected by VE/MVV nor by EELV.

Pleural pressure distribution and its relationship to lung volume and interstitial pressure

The mechanics of the pleural space has long been controversial. We summarize recent research pertaining to pleural mechanics within the following conceptual framework, which is still not universally accepted. Pleural pressure, the force acting to inflate the lung within the thorax, is generated by the opposing elastic recoils of the lung and chest wall and the forces generated by respiratory muscles. The spatial variation of pleural pressure is a result of complex force interactions among the lung and other structures that make up the thorax. Gravity contributes one of the forces that act on these structures, and regional lung expansion and pleural pressure distribution change with changes in body orientation. Forces are transmitted directly between the chest wall and the lung through a very thin but continuous pleural liquid space. The pressure in pleural liquid equals the pressure acting to expand the lung. Pleural liquid is not in hydrostatic equilibrium, and viscous flow of pleural liquid is driven by the combined effect of the gravitational force acting on the liquid and the pressure distribution imposed by the surrounding structures. The dynamics of pleural liquid are considered an integral part of a continual microvascular filtration into the pleural space. Similar concepts apply to the pulmonary interstitium. Regional differences in lung volume expansion also result in regional differences in interstitial pressure within the lung parenchyma and thus affect regional lung fluid filtration.

Lung volumes during low-intensity steady-state cycling

The use of inspiratory capacity (IC) to estimate end-expiratory lung volume (EELV) during exercise has been questioned because of the assumption of constant total lung capacity (TLC). To investigate lung volumes during low-intensity steady-state cycling, we measured EELV by the open-circuit N2 washout method (MR-1, currently Sensormedics 2100) in eight healthy men while at rest and during unloaded and 60-W cycling. TLC was calculated by adding EELV and IC. Measurement variation of TLC was 142 ml at rest, 121 ml during unloaded cycling, and 158 ml during 60-W cycling. TLC did not differ significantly among the three conditions studied. EELV decreased during unloaded (P less than 0.002) and 60-W cycling (P less than 0.001) compared with rest. End-inspiratory lung volume increased only during 60-W cycling (P = 0.03). The decrease in EELV accounted for 100% of the increase in tidal volume during unloaded cycling. Although minute ventilation was similar in the subjects during unloaded cycling, we noted that breathing patterns varied among the subjects. The increase in respiratory frequency was negatively correlated to the change in tidal volume (R2 = 0.54, P = 0.038) and to the change in end-inspiratory lung volume (R2 = 0.68, P = 0.012). We conclude that TLC does not differ significantly during low-intensity steady-state cycling and that use of IC to estimate changes in EELV is appropriate.

Effect of mild-to-moderate airflow limitation on exercise capacity

To determine the effect of mild-to-moderate airflow limitation on exercise tolerance and end-expiratory lung volume (EELV), we studied 9 control subjects with normal pulmonary function [forced expired volume in 1 s (FEV1) 105% pred; % of forced vital capacity expired in 1 s (FEV1/FVC%) 81] and 12 patients with mild-to-moderate airflow limitation (FEV1 72% pred; FEV1/FVC % 58) during progressive cycle ergometry. Maximal exercise capacity was reduced in patients [69% of pred maximal O2 uptake (VO2max)] compared with controls (104% pred VO2max, P less than 0.01); however, maximal expired minute ventilation-to-maximum voluntary ventilation ratio and maximal heart rate were not significantly different between controls and patients. Overall, there was a close relationship between VO2max and FEV1 (r2 = 0.62). Resting EELV was similar between controls and patients [53% of total lung capacity (TLC)], but at maximal exercise the controls decreased EELV to 45% of TLC (P less than 0.01), whereas the patients increased EELV to 58% of TLC (P less than 0.05). Overall, EELV was significantly correlated to both VO2max (r = -0.71, P less than 0.001) and FEV1 (r = -0.68, P less than 0.001). This relationship suggests a ventilatory influence on exercise capacity; however, the increased EELV and associated pleural pressures could influence cardiovascular function during exercise. We suggest that the increase in EELV should be considered a response reflective of the effect of airflow limitation on the ventilatory response to exercise.

Diaphragm dysfunction and respiratory insufficiency after upper abdominal surgery

This study was designed to determine the contribution of diaphragm dysfunction and pain to respiratory insufficiency after upper abdominal surgery. Respiratory insufficiency and postoperative pain in humans were evaluated by pulse oximetry, pulmonary function tests, and a visual analog scale. Diaphragm shortening in dogs was evaluated with biplane videoroentgenography. In humans, despite reasonable pain control, pulmonary function, as reflected in forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and arterial oxygen saturation (SpO2) were significantly reduced on the first postoperative day. Improved pain control was not associated with improvements in FVC or FEV1. In the dogs, diaphragm shortening and tidal volume were significantly reduced in the immediate postoperative period. Phrenic nerve stimulation immediately after surgery resulted in supramaximal diaphragm shortening, which indicated neither the diaphragm nor phrenic nerves were significantly injured by surgical manipulation. Diaphragm dysfunction has a major role in postoperative pulmonary insufficiency; an afferent-mediated reflex inhibition of the phrenic nerves may be responsible.

Effect of body position on regional diaphragm function in dogs

The in situ lengths of muscle bundles of the crural and three regions of the costal diaphragm between origin and insertion were determined with a video roentgenographic technique in dogs. At total lung capacity (TLC) in both the prone and supine positions, the length of the diaphragm is not significantly different from the unstressed excised length, suggesting that the diaphragm is not under tension at TLC and that there is a hydrostatic gradient of pleural pressure on the diaphragmatic surface. Except for the ventral region of the costal diaphragm, which does not change length at lung volumes greater than 70% TLC, all other regions are stretched during passive deflations from TLC. Therefore below TLC the diaphragm is under passive tension and supports a transdiaphragmatic pressure (Pdi). The length of the diaphragm relative to its unstressed length is not uniform at functional residual capacity (FRC) and does not follow a strict vertical gradient that reverses when the animal is changed from the supine to the prone position. By inference, the length of muscle bundles is determined by factors other than the vertical gradient of Pdi. During mechanical ventilation, regional shortening is identical to the passive deflation length-volume relationship near FRC. Prone and supine FRC is the same, but the diaphragm is slightly shorter in the prone position. In both positions, during spontaneous ventilation there are no consistent differences in regional fractional shortening, despite regional differences in initial length relative to unstressed length.

Effects of body position and lung volume on in situ operating length of canine diaphragm

The performance of the diaphragm is influenced by its in situ length relative to its optimal force-generating length (Lo). Lead markers were sutured to the abdominal surface of the diaphragm along bundles of the left ventral, middle, and dorsal regions of the costal diaphragm and the left crural diaphragm of six beagle dogs. After 2-3 wk postoperative recovery, the dogs were anesthetized, paralyzed, and scanned prone and supine in the Dynamic Spatial Reconstructor (DSR) at a total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV). The location of each marker was digitized from the reconstructed DSR images, and in situ lengths were determined. After an overdose of anesthetic had been administered to the dogs, each marked diaphragm bundle was removed, mounted in a 37 degrees C in vitro chamber, and adjusted to Lo (maximum tetanic force). The operating length of the diaphragm, or in situ length expressed as percent Lo, varied from region to region at the lung volumes studied; variability was least at RV and increased with increasing lung volume. At FRC, all regions of the diaphragm was shorter in the prone posture compared with the supine, but there was no clear gravity-dependent vertical gradient of in situ length in either posture. Because in vitro length-tension characteristics were similar for all diaphragm regions, regional in vivo length differences indicate that the diaphragm's potential to generate maximal force is nonuniform.