Effect of optimization of hemodynamics on fibrinolytic activity and antithrombotic efficacy of external pneumatic calf compression

External pneumatic calf compression is effective but imperfect for antithrombotic prophylaxis in surgical patients. In preliminary studies, sequential filling of multisegmented leggings with graded pressure decreasing from ankle to knee increased venous flow velocity and wall shear stress, decreased residual venous volume, and enhanced postoperative fibrinolysis more than uniform compression. To determine if improved hemodynamics also increased antithrombotic activity, we performed a prospective randomized trial in neurosurgical patients comparing sequential application of graded pressure with uniform pressure applied to either a segmented bladder or to a single bladder. Deep vein thrombosis was diagnosed by leg scanning and impedance plethysmography and confirmed by phlebography. Venous thrombosis developed in 3 of 45 patients with graded-sequential filling, 6 of 50 with uniform compression-multiple compartments, and 3 of 41 with uniform pressure single bladder (differences not significant). These results suggest either that uniform compression offers all that can be expected of external pneumatic calf compression in prevention of venous thrombosis, or that even if a study with greater statistical power showed graded-sequential filling to be superior, the benefit/cost ratio of the more complex latter system is not likely to be large.

Gas exchange during constant flow ventilation with different gases

To investigate the mechanisms of CO2 transport during constant flow ventilation, we measured arterial blood gases using air, 80% He-20% O2 (He) or 80% SF6-20% O2 (SF6) as the insufflating gas. At any given flow rate (0.2 to 1.0 L/s), PaCO2 was greatest with He and lowest with SF6. Data for all gases could be described by the equation PaCO2/Pb = 0.044 V-0.64 v0.23, where Pb = barometric pressure, PaCO2 is in mm Hg, V = insufflated flow in L/s, and v = kinematic viscosity (cm2/s). At any given flow rate, the AaPO2 was greater using SF6 than using He. These results are consistent with a 2-zone model of gas transport in which the enhancement of gas transport as V increases may be due to an increase in the turbulent diffusivity in zone I (the region affected by the jet). The decreased gas transport with He compared to air and SF6 at any V may be due to either the decreased penetration depth of zone I caused by the greater kinematic viscosity of He, or the decreased rate of gas transport in the region affected by cardiogenic oscillations (zone II) secondary to the higher molecular diffusivity of He.

A cellular model of lung elasticity

The mechanics of the lung parenchyma is studied using models comprised of line members interconnected to form 3-D cellular structures. The mechanical properties are represented as elastic constants of a continuum. These are determined by perturbing each individual cell from a reference state by an increment in stress which is superimposed upon the uniform stretching forces initially present in the members due to the transpulmonary pressure. A force balance on the distorted structure, together with a force-deformation law for the members, leads to a calculation of the strain increments of the members. Predictions based on the analysis of the 3-D isotropic dodecahedron are in good agreement with experimental values for the Young's, shear, and bulk moduli reported in the literature. The model provides an explanation for the dependence of the elastic moduli on transpulmonary pressure, the geometrical details of the structure, and the stress-strain law of the tissue.

Effects of gas properties and waveform asymmetry on gas transport in a branching tube network

Local gas transport coefficients, quantifying longitudinal dispersion through a symmetrical constant-diameter tube network, have been measured during oscillation with both symmetrical and nonsymmetrical waveforms. Experiments were carried out over a range of conditions that would prevail in the central to lower airways during high-frequency ventilation at moderate frequency (5 Hz) and tidal volume (15-80 ml). Gas transport coefficients resulting from oscillation of three different resident-trace gas pairs were measured using a new analytic technique. This technique allowed rapid determination of the transport coefficient distribution along the entire network. Results demonstrate a small but significant influence attributable to changes in gas properties that is similar to that found in a straight tube and indicate that augmented dispersion is an important mechanism of axial transport. Gas transport coefficients were found to be unaffected by changes in flow waveform symmetry, suggesting that previously reported improvements in gas exchange associated with decreasing inspiratory to expiratory time ratios are not due to a change in local conditions such as asymmetry in the velocity profile.

Choking phenomena in a lung-like model

A simple, continuous, one-dimensional model for the geometry and structure of the bronchial airways is used for the analysis of fluid flow patterns which have been observed in forced expiration maneuvers. Various phenomena within the conducting system associated with flow limitation are investigated: the conditions in which a "choke" (flow limitation) can occur in a compliant system; theoretical flows that are physically impossible; the possibility of having elastic jumps downstream of the choke point; perturbations in the physical parameters of the conducting system.

Calculations of flow resistance in the juxtacanalicular meshwork

The structure of the juxtacanalicular meshwork (JCM) was analyzed morphometrically, and the resulting data were used to calculate the resistance to flow through this tissue. Two models of the JCM were presented and compared. In the first (Model A), aqueous humor was assumed to flow via open channels within a solid framework, while, in the second (Model B), these open spaces were assumed to be filled with extracellular matrix gel. An expression giving the resistance of such a gel as a function of gel concentration was presented and tested on corneal and scleral stroma. Morphometry of normal and glaucomatous human eyes showed that Model A underpredicted the resistance of the JCM by factors of 10-100, suggesting that a GAG or proteoglycan gel may control the flow resistance of this tissue. This was supported by Model B, which showed that measured bulk concentrations of GAGs were consistent with gel concentrations needed to account for the estimated resistance of the JCM in vivo. Some limitations and implications of Model B were discussed.

The effect of a turbulent jet on gas transport during oscillatory flow

Axial mass transport due to the combined effects of flow oscillation and a turbulent jet was studied both experimentally and with a simple theoretical model. The experiments show that the distance over which turbulence enhances transport is greatly increased by flow oscillation, and is particularly sensitive to tidal volume. The jet flow rate and jet configuration are relatively less important. To analyze the results, the region influenced by the jet is divided into two zones: a near field in which the time-mean flow velocities are larger than the turbulent fluctuations, and a far field where the time-mean flow is essentially zero. In the far field, axial mass transport is increased due to the turbulence which decays in strength away from the jet. When oscillatory flow is superimposed upon the steady jet flow, the turbulence in the far field interacts with the flow oscillations to augment the transport of turbulence energy and of mass. This transport enhancement is modeled by introducing an effective axial diffusivity analogous to that used in laminar oscillatory flow.

Effect of flow rate on blood gases during constant flow ventilation in dogs

We studied the effect of flow rate (V) on arterial blood gases during constant flow ventilation (CFV) in 9 anesthetized, paralyzed dogs weighing 9.5 to 26.5 kg. The constant flow was administered through catheters placed in each mainstem bronchus. Alveolar ventilation increased linearly with increasing V over the range of 0.18 to 1.0 L/s but was relatively constant at flows above 1.0 L/s. We found that CFV produced normocapnia at a mean V of 0.48 +/- 0.21 L/s (mean +/- SD). However, we did not find any significant relationship between body weight and the V required for normocapnia. At all flow rates we found a relatively large alveolar to arterial oxygen difference (48.9 +/- 8.8 mmHg, mean +/- SD), suggesting significant inhomogeneities in ventilation-perfusion. Our data are consistent with a 2-zone model of gas exchange where gas exchange is dominated by bidirectional convective streaming in the airways closest to the jets, cardiogenic induced flows in the most peripheral airways, and jet-induced turbulence in those airways between these 2 regions.

The flow of aqueous humor through micro-porous filters

Flow resistance was measured as bovine and primate aqueous humor was passed through Nuclepore polycarbonate filters having flow dimensions similar to those found within the juxtacanalicular meshwork of the aqueous outflow network. The results indicate that aqueous humor has a greater flow resistance than isotonic saline; this greater resistance is attributable to proteins or glycoproteins in aqueous humor that obstruct the filters. If the same phenomenon is operative in the aqueous outflow network, it would help to explain discrepancies between calculated and measured aqueous outflow resistance.

Relationship for gas transport during high-frequency ventilation in dogs

Alveolar ventilation during high-frequency ventilation (HFV) was estimated from the washout of the positron-emitting isotope (nitrogen-13-labeled N2) from the lungs of anesthetized paralyzed supine dogs by use of a positron camera. HFV was delivered at a mean lung volume (VL) equal to the resting functional residual capacity with a ventilator that generated tidal volumes (VT) between 30 and 120 ml, independent of the animal's lung impedance, at frequencies (f) from 2 to 25 Hz, with constant inspiratory and expiratory flows and an inspiration-to-expiration time ratio of unity. Specific ventilation (SPV), which is equivalent to ventilation per unit of compartment volume, was found to follow closely the relation: SPV = 1.9(VT/VL)2.1 X f. From this relation and from arterial PCO2 measurements we found an expression for the normocapnic settings of VT and f, given VL and body weight (W). We found that the VL was an important normalizing parameter in the sense that VT/VL yielded a better correlation (r = 0.91) with SPV/f than VT/W (r = 0.62) or VT alone (r = 0.8).

Gas transport during oscillatory flow in a network of branching tubes

A transport coefficient was measured for a range of oscillatory flow conditions in a branching network of tubes. Measurements were made both across the first generation of a three-generation network and the second generation of a four-generation network. The results for these two series of tests were similar, indicating that there was no significant effect due to the system boundaries. The results are cast in terms of an effective axial diffusion coefficient of the form (Formula: see text) where kappa is the molecular diffusivity, Vt is the local stroke volume (cc); and f is the oscillation frequency (Hz). These results are compared to those obtained by other investigators in branching systems of similar geometry. At low frequency, this result is found to be in approximate agreement with the steady flow result of Scherer, et al. [15]. This expression differs from the oscillatory flow results of Tarbell, et al. [19] for liquids, primarily in terms of the effects of oscillation frequency.

Pressure excursions during oscillatory flow in a branching network of tubes

The pressure difference across individual branches of a four-generation network of branching tubes was measured with the objective of obtaining general laws to describe the pressure drop in the airways under conditions of oscillatory flow. Fourier decomposition showed that the pressure signals consisted of a dominant component at the excitation frequency ("fundamental") and a "first harmonic" of smaller magnitude. For values of the ratio Re/alpha less than 200, the fundamental mainly represented fluid acceleration, whereas the first harmonic reflected the effects both of viscous dissipation and the change in total cross-sectional area between parent and daughter generations. For values of Re/alpha greater than 200, the magnitude of the fundamental was considerably larger than that due to fluid acceleration alone, suggesting the possibility of onset of turbulence in the branching network. These pressure measurements were applied to a simple model of the dog lung to predict total airway resistance. The results are found to be in substantial agreement with physiological measurements.

Gas mixing during high-frequency ventilation: an improved model

A model for gas transport during high-frequency ventilation incorporating recently derived empirical forms for the effective diffusivity in oscillatory gas flow through a symmetrical branching network is proposed. The model accounts for the movement of gas among airways with changing cross-sectional area by using a moving-reference-frame analysis. The analysis technique incorporates the convective purging of the bias flow at the airway opening. The model predicts that although the cycle-averaged CO2 elimination rate (VCO2) depends most strongly on the product of frequency and tidal volume (VT), VT has an effect on its own, a finding consistent with published observations. This "VT effect" is due primarily to the oscillatory movement of gas from more central regions into peripheral regions where large cross-sectional areas promote efficient CO2 transport by molecular diffusion. Although the VT effect exists independent of the presence of a bias flow, placing the bias flow near the main carina can enhance the VT effect substantially. As VT is increased to values in the range of ordinary tidal breaths, VCO2 predicted by the model achieves close agreement with VCO2 deduced from conventional gas exchange theory.

High-frequency ventilation

Complete physiological understanding of HFV requires knowledge of four general classes of information: 1) the distribution of airflow within the lung over a wide range of frequencies and VT (sect. IVA), 2) an understanding of the basic mechanisms whereby the local airflows lead to gas transport (sect. IVB), 3) a computational or theoretical model in which transport mechanisms are cast in such a form that they can be used to predict overall gas transport rates (sect. IVC), and 4) an experimental data base (sect. VI) that can be compared to model predictions. When compared with available experimental data, it becomes clear that none of the proposed models adequately describes all the experimental findings. Although the model of Kamm et al. is the only one capable of simulating the transition from small to large VT (as compared to dead-space volume), it fails to predict the gas transport observed experimentally with VT less than equipment dead space. The Fredberg model is not capable of predicting the observed tendency for VT to be a more important determinant of gas exchange than is frequency. The remaining models predict a greater influence of VT than frequency on gas transport (consistent with experimental observations) but in their current form cannot simulate the additional gas exchange associated with VT in excess of the dead-space volume nor the decreased efficacy of HFV above certain critical frequencies observed in both animals and humans. Thus all of these models are probably inadequate in detail. One important aspect of these various models is that some are based on transport experiments done in appropriately scaled physical models, whereas others are entirely theoretical. The experimental models are probably most useful in the prediction of pulmonary gas transport rates, whereas the physical models are of greater value in identifying the specific transport mechanism(s) responsible for gas exchange. However, both classes require a knowledge of the factors governing the distribution of airflow under the circumstances of study as well as requiring detail about lung anatomy and airway physical properties. Only when such factors are fully understood and incorporated into a general description of gas exchange by HFV will it be possible to predict or explain all experimental or clinical findings.

Intra-airway gas mixing during high-frequency ventilation

We examined the intra-airway gas transport mediated by high-frequency oscillations (HFO) in 10 nonintubated healthy volunteers using a method based on comparisons of single-breath N2-washout curves obtained after various durations of breath hold or high-frequency oscillations. With a mathematical analysis based on Fick's law of diffusion we computed the local transport parameter, effective diffusivity, during oscillations of frequency 2-24 Hz and tidal volume 10-120 ml and during breath hold alone. Local effective diffusivity increased with both oscillatory frequency and tidal volume at all levels in the tracheobronchial tree; the enhancing effect of tidal volume on local effective diffusivity was more pronounced than that of frequency so that effective diffusivity was greater with larger tidal volume at fixed frequency-tidal volume product (f . VT). The greatest enhancement of gas mixing within the lung during HFO (over breath hold) was seen in the central airways. In previous studies examining CO2 removal rate during HFO (J. Clin. Invest. 68: 1475, 1981), we found that CO2 output was also greater with larger tidal volume at fixed f . VT, and we attributed this to an end constraint imposed by a fresh gas bias flow. Results of the current study, performed without a bias flow, indicate that bias flow end constraint does not solely account for the observed dependence of CO2 output on frequency and tidal volume.

Measurements of the compressive properties of scleral tissue

Tests were conducted on small samples of sclera taken from cattle eyes and human eyes to determine the mechanical properties of the tissue in compression. It was found that the elastic modulus for radial compressive stress of human sclera was more than a factor of 100 less than the modulus for circumferential tensile stress. The stress-strain relationship was found to be mildly nonlinear and exhibited hysteresis when cycled through a pattern of increasing-then-decreasing stress. Given sufficient time, however, the sample returned to its original state and, therefore, exhibited no permanent deformation. Measurements of Poisson's ratio yielded values of 0.46 to 0.50, indicating that these samples were essentially incompressible.

The role of Schlemm's canal in aqueous outflow from the human eye

A mathematical model of Schlemm's canal is developed to simulate collapse of the canal and its effect on resistance to flow through the aqueous outflow network. Schlemm's canal is modeled as a porous, compliant channel that is held open by the trabecular meshwork. The trabecular meshwork is modeled as a series of linear springs that allow the inner wall of Schlemm's canal to deform in proportion to the local pressure drop across it. Based on comparisons between the model and results in the literature, the following tentative conclusions are reached: (1) Most of the resistance in the aqueous outflow network occurs in the inner wall of Schlemm's canal. (2) Glaucoma is not caused by a weakening of the trabecular meshwork and a resultant collapse of Schlemm's canal alone. Instead, glaucoma probably results from an increased flow resistance of the inner wall of the canal.

Filling of partially collapsed compliant tubes

Filling of a thin-walled, highly compliant tube in a partially collapsed condition is studied. The theory, based on one-dimensional flow, takes account of friction, longitudinal tension, and the highly nonlinear pressure-area law for the tube. Various aspects of filling behavior are revealed by alternative calculations using: (i) the method of characteristics; (ii) numerical integration of the continuity, momentum, and tube-law equations; and (iii) a crude but simple lumped-element capacitance-inertance-resistance model. Varied phenomena appear. At high Reynolds number, these include dispersive wave trains associated with circumferential bending stiffness and longitudinal tension, nonlinear changes of wave form, development of highly asymmetrical wave reflections, and sloshing. At low Reynolds number, the area changes with time in a diffusivelike manner. The experiments exhibited the dispersive phenomena predicted by the theory.

CO2 elimination by high-frequency oscillations in dogs--effects of histamine infusion

Effective gas exchange can be achieved in normal dogs by ventilation at frequencies of 4-20 Hz using stroke volumes (SV) smaller than the anatomic dead space. CO2 elimination is largely a function of tracheal SV-frequency product (Vosc) in anesthetized, paralyzed dogs with normal lungs. To determine the effect of constriction of small airways on gas exchange during such high-frequency ventilation (HFV), we ventilated five anesthetized, paralyzed, and vagotomized dogs via a tracheal cannula before and during intravenous histamine infusion. Vosc was varied by varying the frequency while keeping SV constant. For low Vosc, CO2 elimination (VCO2) increased directly with Vosc during control and histamine experiments. At high Vosc, VCO2 continued to increase directly with Vosc during the control study, but during histamine infusion VCO2 was lower than control values. Eucapnia could be maintained in each dog during HFV, even during airway constriction. During histamine infusion the frequency-dependent mechanical properties of the lung influence the delivery of the HFV SV to the respiratory zone, and this may explain the lower VCO2 observed.

Bioengineering studies of periodic external compression as prophylaxis against deep vein thrombosis-part I: numerical studies

This paper presents the results of a numerical study of the technique of periodic external compression for the prevention of deep vein thrombosis. In the model the veins of the lower leg are portrayed as a continuous system rather than as discrete elements as in previous models. Consequently, we are able to explore the detailed effects of different modes of compression including (i) uniform compression, the simultaneous application of uniform pressure over the entire lower leg, (ii) graded compression, the application of nonuniform pressure, maximum at the ankle and minimum at the knee, and (iii) wavelike compression, a wave of compression proceeding from the ankle toward the knee. These numerical results indicate that the effectiveness of uniform compression is severely compromised by the formation of a flow-limiting throat at the proximal end of the compression cuff that reduces both the rate at which blood is discharged from the lower leg and the total blood volume removed. Both of these detrimental effects can be avoided by the use of either wavelike of graded compression. Both alternated methods are shown to produce more uniform augmentation of volume flow rate, flow velocity and shear stress, throughout the entire lower leg. In the companion paper, Part II [18] (see following article), these same compression modes are tested using a simple hydraulic model consisting of a single latex tube inside a foam cylinder as a highly simplified representation of a human leg.

Bioengineering studies of periodic external compression as prophylaxis against deep vein thrombosis-part II: experimental studies on a stimulated leg

In this companion paper to "Part I: Numerical Simulations, " we report in vitro experimental studies performed on a simple model leg consisting of a "vein" of thin-walled latex tubing surrounded by "tissue" of open-pore foam rubber. Three modes of periodic external compression, were investigated: i) uniform compression; (ii) graded compression, decreasing from ankle to knee; and (iii) sequential compression, progressing from ankle to knee. The modes are compared on the basis of three hemodynamic criteria: degree of vessel collapse, level of fluid velocity, and level of shear stress. In uniform compression these measures of merit are distributed very nonuniformly along the length of the leg: they are high near the proximal end of the cuff but low elsewhere, a result due to the formation proximally of a partially occlusive throat. The latter does not form in either graded or sequential compression, with the consequence that favorable values of the three measures of merit occur more uniformly along the length of the pressurized region. It is concluded that either the graded or sequential mode of compression, or perhaps a combination of the two, would be more effective than uniform compression as a prophylaxis against deep vein thrombosis.

Effects of frequency, tidal volume, and lung volume on CO2 elimination in dogs by high frequency (2-30 Hz), low tidal volume ventilation

Recent studies have shown that effective pulmonary ventilation is possible with tidal volumes (VT) less than the anatomic dead-space if the oscillatory frequency (f) is sufficiently large. We systematically studied the effect on pulmonary CO2 elimination (VCO2) of varying f (2-30 Hz) and VT (1-7 ml/kg) as well as lung volume (VL) in 13 anesthetized, paralyzed dogs in order to examine the contribution of those variables that are thought to be important in determining gas exchange by high frequency ventilation. All experiments were performed when the alveolar PCO2 was 40 +/- 1.5 mm Hg. In all studies, VCO2 increased monotonically with f at constant VT. We quantitated the effects of f and VT on VCO2 by using the dimensionless equation VCO2/VOSC = a(VT/VTo)b(f/fo)c where: VOSC = f X VT, VTo = mean VT, fo = mean f and a, b, c, are constants obtained by multiple regression. The mean values of a, b, and c for all dogs were 2.12 X 10(-3), 0.49, and 0.08, respectively. The most important variable in determining VCO2 was VOSC; however, there was considerable variability among dogs in the independent effect of VT and f on VCO2, with a doubling of VT at a constant VOSC causing changes in VCO2 ranging from -13 to +110% (mean = +35%). Increasing VL from functional residual capacity (FRC) to the lung volume at an airway opening minus body surface pressure of 25 cm H2O had no significant effect on VCO2.