Theoretical basis of single breath gas absorption tests

Alveolar-capillary reserve during exercise in patients with chronic obstructive pulmonary disease

Background

Factors limiting exercise in patients with COPD are complex. With evidence for accelerated pulmonary vascular aging, destruction of alveolar-capillary bed, and hypoxic pulmonary vasoconstriction, the ability to functionally expand surface area during exercise may become a primary limitation.

Purpose

To quantify measures of alveolar-capillary recruitment during exercise and the relationship to exercise capacity in a cohort of COPD patients.

Methods

Thirty-two subjects gave consent (53% male, with mean ± standard deviation age 66±9 years, smoking 35±29 pack-years, and Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of 0-4: 2.3±0.8), filled out the St George's Respiratory Questionnaire (SGRQ) to measure quality of life, had a complete blood count drawn, and underwent spirometry. The intrabreath (IB) technique for lung diffusing capacity for carbon monoxide (IBDLCO) and pulmonary blood flow (IBQc, at rest) was also performed. Subsequently, they completed a cycle ergometry test to exhaustion with measures of oxygen saturation and expired gases.

Results

Baseline average measures were 44±21 for SGRQ score and 58±11 for FEV₁/FVC. Peak oxygen consumption (VO₂) was 11.4±3.1 mL/kg/min (49% predicted). The mean resting IBDLCO was 9.7±5.4 mL/min/mmHg and IBQc was 4.7±0.9 L/min. At the first workload, heart rate (HR) increased to 92±11 bpm, VO₂ was 8.3±1.4 mL/kg/min, and IBDLCO and IBQc increased by 46% and 43%, respectively, compared to resting values (p,0.01). The IBDLCO/Qc ratio averaged 2.0±1.1 at rest and remained constant during exercise with marked variation across subjects (range: 0.8-4.8). Ventilatory efficiency plateaued at 37±5 during exercise, partial pressure of mix expired CO₂/partial pressure of end tidal CO₂ ratio ranged from 0.63 to 0.67, while a noninvasive index of pulmonary capacitance, O₂ pulse × PetCO₂ (GxCap) rose to 138%. The exercise IBDLCO/Qc ratio was related to O₂ pulse (VO₂/HR, r=0.58, p<0.01), and subjects with the highest exercise IBDLCO/Qc ratio or the greatest rise from rest had the highest peak VO₂ values (r=0.65 and 0.51, respectively, p<0.05). Of the noninvasive gas exchange measures of pulmonary vascular function, GxCap was most closely associated with DLCO, DLCO/Qc, and VO₂ peak.

Conclusion

COPD patients who can expand gas exchange surface area as assessed with DLCO during exercise relative to pulmonary blood flow have a more preserved exercise capacity.

Influence of resting lung diffusion on exercise capacity in patients with COPD

Background

Lung diffusing capacity for carbon monoxide (DLCO) gives an overall assessment of functional lung surface area for gas exchange and can be assessed using various methods. DLCO is an important factor in exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). We investigated if the intra-breath (IBDLCO) method may give a more sensitive measure of available gas exchange surface area than the more typical single breath (SBDLCO) method and if COPD subjects with the largest resting DLCO relative to pulmonary blood flow (Qc) would have a more preserved exercise capacity.

Methods

Informed consent, hemoglobin, spirometry, SBDLCO, IBDLCO, and Qc during IBDLCO were performed in moderate to severe COPD patients, followed by progressive cycle ergometry to exhaustion with measures of oxygen saturation (SaO₂) and expired gases.

Results

Thirty two subjects (47% female, age 66 ± 9 yrs., BMI 30.4 ± 6.3 kg/m², smoking hx 35 ± 29 pkyrs, 2.3 ± 0.8 on the 0-4 GOLD classification scale) participated. The majority used multiple inhaled medications and 20% were on oral steroids. Averages were: FEV₁/FVC 58 ± 10%Pred, peak VO₂ 11.4 ± 3.1 ml/kg/min, and IBDLCO 72% of the SBDLCO (r = 0.88, SB vs IB methods). Using univariate regression, both the SB and IBDLCO (% predicted but not absolute) were predictive of VO₂peak in ml/kg/min; SBDLCO/Qc (r = 0.63, p < 0.001) was the best predictor of VO₂peak; maximal expiratory flows over the mid to lower lung volumes were the most significantly predictive spirometric measure (r = 0.49, p < 0.01). However, in multivariate models only BMI added additional predictive value to the SBDLCO/Qc for predicting aerobic capacity (r = 0.73). Adjusting for current smoking status and gender did not significantly change the primary results.

Conclusion

In patients with moderate to severe COPD, preservation of lung gas exchange surface area as assessed using the resting SBDLCO/Qc appears to be a better predictor of exercise capacity than more classic measures of lung mechanics.

Reduced exercise tolerance and pulmonary capillary recruitment with remote secondhand smoke exposure

Rationale

Flight attendants who worked on commercial aircraft before the smoking ban in flights (pre-ban FAs) were exposed to high levels of secondhand smoke (SHS). We previously showed never-smoking pre-ban FAs to have reduced diffusing capacity (Dco) at rest.

Methods

To determine whether pre-ban FAs increase their Dco and pulmonary blood flow () during exercise, we administered a symptom-limited supine-posture progressively increasing cycle exercise test to determine the maximum work (watts) and oxygen uptake () achieved by FAs. After 30 min rest, we then measured Dco and at 20, 40, 60, and 80 percent of maximum observed work.

Results

The FAs with abnormal resting Dco achieved a lower level of maximum predicted work and compared to those with normal resting Dco (mean±SEM; 88.7±2.9 vs. 102.5±3.1%predicted ; p = 0.001). Exercise limitation was associated with the FAs' FEV₁ (r = 0.33; p = 0.003). The Dco increased less with exercise in those with abnormal resting Dco (mean±SEM: 1.36±0.16 vs. 1.90±0.16 ml/min/mmHg per 20% increase in predicted watts; p = 0.020), and amongst all FAs, the increase with exercise seemed to be incrementally lower in those with lower resting Dco. Exercise-induced increase in was not different in the two groups. However, the FAs with abnormal resting Dco had less augmentation of their Dco with increase in during exercise (mean±SEM: 0.93±0.06 vs. 1.47±0.09 ml/min/mmHg per L/min; p<0.0001). The Dco during exercise was inversely associated with years of exposure to SHS in those FAs with ≥10 years of pre-ban experience (r = −0.32; p = 0.032).

Conclusions

This cohort of never-smoking FAs with SHS exposure showed exercise limitation based on their resting Dco. Those with lower resting Dco had reduced pulmonary capillary recruitment. Exposure to SHS in the aircraft cabin seemed to be a predictor for lower Dco during exercise.

Stroke volume response during exercise measured by acetylene uptake and MRI

The intra-breath technique to measure acetylene absorption offers the possibility to determine augmentation of the pulmonary blood flow per heart beat (Q(C)) as an estimate of the stroke volume response during exercise. However, this method has not been compared with a validated test until now. Therefore, the aim of this study was to compare Q(C) with stroke volume (SV(MRI)) determined by magnetic resonance imaging (MRI) at rest and during exercise in healthy subjects and patients. For this purpose, ten healthy subjects and ten patients with idiopathic pulmonary arterial hypertension (iPAH) with expected impaired stoke volume response during exercise were measured by both methods. Exercise-induced changes in Q(C) and SV(MRI) were correlated in healthy controls (r = 0.75, p < 0.05). Compared to healthy controls, Q(C) increased less during exercise in iPAH patients (11 +/- 17 ml versus 33 +/- 12 ml, p < 0.05). A similar difference in stroke volume response to exercise between the two groups was measured by MRI (-0.6 +/- 8 ml versus 23 +/- 12 ml, p < 0.05, respectively). Hence, intra-breath and MRI measurements showed similar differences in exercise-induced changes in stroke volume between controls and patients. From these results it can be concluded that the intra-breath measurement of acetylene absorption might be of value as a non-invasive tool to estimate stroke volume augmentation during exercise and can detect differences in stroke volume responses between iPAH patients and healthy subjects.

Intrabreath analysis of carbon monoxide uptake during exercise in patients at risk for lung injury

The single exhalation analysis of carbon monoxide, acetylene, and methane allows the determination of intrabreath (regional) DL, pulmonary capillary blood flow and ventilation inhomogeneities during rest and exercise. We reasoned that this technique might be more sensitive in detecting regional pulmonary capillary abnormalities than resting single breath DL (DL(sb)). We selected a group of breast cancer patients in high-dose chemotherapy (HDCT) protocols who were at risk for pulmonary injury. We grouped the patients into pre-HDCT and post-HDCT, and used resting DL(sb) to further categorize the latter into those with and without pulmonary injury. We found that exercise DL increases were blunted in post-HDCT patients with low resting DL(sb). More importantly, even in post-HDCT patients with normal resting DL(sb), exercise DL response was reduced in the slowest emptying lung units along with evidence for ventilation inhomogeneities (increased methane slope). We conclude that exercise assessments of DL at low lung volumes and gas mixing properties may be sensitive indicators of lung injury.

Influence of unequal ventilation on the single breath K(CO) in COPD revealed by comparison with the rebreathing K(CO)

In 16 patients with chronic obstructive pulmonary disease (COPD) we investigated the relation between unequal ventilation and diffusion by means of lung volumes and Krogh factors (K(CO)) using the single breath (SB) and the rebreathing (RB) methods. We used both methods because the SB measurement is sensitive to unequal ventilation and diffusion whereas the RB measurement is not. Because K(CO) depends on inspired volume (VI), the SB and RB measurement have to be performed at the same VI. We therefore determined K(CO)SBm by making a SB measurement at VI equal to the mean inspired volume during the RB measurement and then calculated K(CO)RBm by dividing the RB transfer factor for CO by the mean RB lung volume. In 10 patients K(CO)SBm/K(CO)RBm, a parameter determined by the combined effect of unequal ventilation and diffusion, was almost equal to unequal ventilation, the quotient of the SB and mean RB lung volumes (VSBm/VRBm), just as in normal subjects (Jansons et al., Respiration 67 (2000) 383). This finding means that we can correct for the effects of unequal ventilation by dividing K(CO)SBm by VSBm/VRBm. We suggest that the SB measurement of K(CO) at vital capacity can be corrected in a similar way.

Intrabreath diffusing capacity of the lung in healthy individuals at rest and during exercise

BACKGROUND

Traditional approaches to measuring the diffusing capacity of the lung for carbon monoxide (DLCO) treat the lung as a single, well-mixed compartment and produce a single value for DLCO to represent an average diffusing capacity of the lung (DL). Because DL distribution in the lung is inhomogeneous, and changes in the DL in diseased lungs may be regional, measuring regional DL, especially during exercise, may be more sensitive in detecting pulmonary vascular diseases.

OBJECTIVES

To characterize regional changes in DL in healthy individuals from rest to exercise, and to provide normal references for future studies in pulmonary vascular disorders.

METHODS

We reanalyzed DLCO and phase III CH(4) slopes that were obtained during a slow, single exhalation at rest and during exercise in our extended database of 105 healthy individuals. DLCO profiles between 20% and 80% of exhaled vital capacity (VC) (ie, the intrabreath DLCO) were analyzed by calculating the average DLCO measured at midlung volume (ie, 30 to 45% of exhaled VC [DLCOMLV]) and by fitting the whole curve with a third-order polynomial equation.

RESULTS

DLCO decreased nonlinearly by approximately 30%, from 20 to 80% of exhaled VC at rest. DLCO during exercise was greater than that at rest, and the increase was similar at all lung volumes. The CH(4) slopes at rest and during exercise were similar. Prediction equations based on regressions on age, sex, and height were computed for resting and exercise DLCOMLV and the phase III CH(4) slope (an index of ventilation distribution).

CONCLUSIONS

Capillary recruitment/dilation during exercise in healthy individuals is a uniform process throughout the lungs. Our analyses provide a database for a noninvasive method that can incorporate exercise to evaluate the volume-dependent distribution of DLCO in lung diseases.

Estimation of the VA/(Q+VTIS) distribution from single-breath alkane uptake

In this paper, it was investigated if the ventilation-perfusion distribution can be estimated from the uptake (U) of inert gases with different solubilities during the single-breath maneuver. A model was implemented that describes U as a function of solubility for inhomogeneously distributed alveolar volume (VA) versus blood and tissue volume (Q + VTIS). The VA/(Q + VTIS) distribution describes the relative contribution of gas-exchange units with different VA/(Q + VTIS) ratios to the expiratory volume. U was derived as the sum of uptakes corresponding to different modes in the distribution, weighted with the relative contribution to the expiratory volume. This permits an estimation of the distribution parameters by fitting U as a function of solubility. The n alkanes were used because of their different solubilities. Analysis of the sensitivity of the estimated VA/(Q + VTIS) distribution parameters to measurement errors showed that mostly two modes can be discerned. The influence of fixed model parameters appeared relatively small. The model could well explain U in normal and emphysematous subjects, with a larger contribution of high VA/(Q + VTIS) ratios in the emphysematous subjects. It was concluded that the VA/(Q + VTIS) distribution can be estimated noninvasively from single-breath alkane uptake.

Lack of improvement of lung diffusing capacity following fluid withdrawal by ultrafiltration in chronic heart failure

OBJECTIVES

We sought to investigate the possibility that lung diffusing capacity reduction observed in chronic heart failure is reversible in the short term.

BACKGROUND

Mechanical properties of the lung usually ameliorate with antifailure treatment including drugs, ultrafiltration and heart transplantation, whereas lung diffusion rarely improves.

METHODS

We studied the mechanical properties of the lung (pulmonary function tests with determination of alveolar volume, extravascular lung fluids and lung tissue), lung diffusion for carbon monoxide (DLco), including membrane diffusing capacity (Dm), pulmonary capillary blood volume (Vc) and pulmonary hemodynamics, in 28 patients with stable chronic heart failure, before a single session of extracorporeal ultrafiltration (3,973 +/- 2200 ml) and four days thereafter. Lung mechanics and diffusion were also evaluated in 18 normal subjects.

RESULTS

Vital capacity, forced expiratory volume (1 s) and maximal voluntary ventilation were lower in patients when compared with normal subjects, and increased after ultrafiltration from 2.1 +/- 0.7 to 2.5 +/- 0.7(1)*, 1.7 +/- 0.5 to 2.0 +/- 0.6(1)* and 67 +/- 25 to 79 +/- 26 (1/min)*, respectively (* p < 0.02 vs. pre-ultrafiltration). Post-ultrafiltration alveolar volume was augmented, while lung tissue, body weight (approximately 6 kg), chest X-ray extravascular lung water score and pulmonary vascular pressure were reduced. Heart dimensions (echocardiography) remained unchanged. DLco, Dm and Vc were 29.0 +/- 5.0 ml/min/mm Hg, 47.0 +/- 11.0 ml/min/mm Hg, 102 +/- 20 ml in normal subjects and 17.1 +/- 4.0#, 24.1 +/- 6.5#, 113 +/- 38 and 17.0 +/- 5.0#, 24.8 +/- 7.9#, 100 +/- 39 in patients before and after ultrafiltration, respectively (# = p < 0.01 vs. controls).

CONCLUSIONS

In chronic heart failure, ultrafiltration improves volumes and mechanical properties of the lung by reducing lung fluids. Diffusion is unaffected by ultrafiltration, suggesting that, in chronic heart failure, the alveolar-capillary membrane abnormalities are fluid-independent.

Effect of alveolar volume and sequential filling on the diffusing capacity of the lungs: II. Experiment

The diffusing capacity of the lung, DL, is a critical physiological parameter, yet the currently accepted clinical model (Jones-Meade) assumes a well-mixed alveolar region, and a constant DL independent of alveolar volume, VA, despite experimental evidence to the contrary. We have formulated a new mathematical model [Tsoukias, N.M, Wilson, A.F., George, S.C., 2000. Respir. Physiol. 120, 231-249] that considers variable alveolar mixing through a single parameter, k (0<k<1), and a DL that is a positive function of VA (DL=a+bVA or DL=alphaVA(beta)). The goal of this study is to determine the suitability of this model to determine the unknown parameters a, b, alpha, beta, and k from experimental data in normal subjects. The model predicts that the normal lung fills, in part, sequentially (k=0.51+/-0.35). The following average values in all seven subjects were obtained: DLNO=48.VA(2/3) ml/min/mmHg and DLCO=20+0.7.VA ml/min/mmHg (STPD) where VA is expressed in L (STPD). We conclude that the mathematical model is suitable for identifying the unknown parameters and thus can be used to characterize the degree of alveolar mixing (or sequential filling) as well as the volume dependence of DL.

Effect of alveolar volume and sequential filling on the diffusing capacity of the lungs: I. theory

The diffusing capacity, DL, is a critical physiological parameter of the lung used to assess gas exchange clinically. Most models developed to analyze experimental data from a single breath maneuver have assumed a well-mixed or uniform alveolar region, including the clinically accepted Jones-Meade method. In addition, all previous models have assumed a constant DL, which is independent of alveolar volume, VA. In contrast, experimental data provide evidence for a non-uniform alveolar region coupled with sequential filling of the lung. In addition, although the DL for carbon monoxide is a weak function of VA, the DL of nitric oxide depends strongly on VA. We have developed a new mathematical model of the single breath maneuver that considers both a variable degree of sequential filling and a variable DL. Our model predicts that the Jones-Meade method overestimates DL when the exhaled gas sample is collected late in the exhalation, but underestimates DL if the exhaled gas sample is collected early in the exhalation phase due to the effect of sequential filling. Utilizing a prolonged constant exhalation method, or a three-equation method, will also produce erroneous predictions of DL. We conclude that current methods may introduce significant error in the estimation of DL by ignoring the sequential filling of the lung, and the dependence of DL on VA.

Noninvasive measurement of cardiac output by an acetylene uptake technique and simultaneous comparison with thermodilution in ICU patients

A simple, accurate, and noninvasive method of cardiac output measurement can be an extremely useful tool for the clinician and researcher. This study used the acetylene gas uptake technique to measure the absorption of acetylene into the pulmonary circulation during a constant exhalation, which is proportional to the pulmonary capillary blood flow and to the cardiac output, assuming no anatomic shunts. We compared cardiac output measured simultaneously by this and by the standard thermodilution (TD) technique in 21 patients in the ICU with a variety of medical and surgical conditions and a wide range of cardiac outputs. We also compared the two techniques in 19 ambulatory patients with a 2-h interval between the invasive and noninvasive test to assess variability over time. The two tests had an excellent correlation when done simultaneously with a correlation coefficient of 0.89 (p < 0.001). With a 2-h interval between the two tests, the correlation coefficient was 0.66 (p = 0.0018). Nine patients in the simultaneous group had cardiomyopathy. When they were excluded, the correlation coefficient increased to 0.96. Most of these patients had documented tricuspid regurgitation (TR), which may underlie the greater difference between acetylene uptake and TD values, with consistently higher TD values in these patients. This study confirms the correlation between the acetylene uptake and the standard invasive TD techniques in sick patients with various medical and surgical conditions and a wide range of cardiac outputs. Furthermore, we believe this would be a more accurate method for measuring cardiac output in patients with cardiomyopathy and TR because it is based only on pulmonary capillary blood flow.

Almost simultaneous measurement of cardiovascular and gas exchange variables during maximal exercise

We measured gas exchange variables such as oxygen uptake, carbon dioxide output, and lung diffusing capacity using noninvasive techniques almost simultaneous with assessment of cardiovascular variables such as pulmonary blood flow at several levels of treadmill exercise up to and including maximal capacity. We utilized a single breath exhalation technique for measurement of diffusing capacity and cardiac output and breath by breath methodology for evaluating oxygen uptake. The equipment required for these measurements--rapid gas analyzers, oximeters, on-line computation, and pneumatic valves--are well within the capabilities of many exercise laboratories and are not difficult to use with subjects even at the heaviest levels of exercise. The results agreed well with values reported in the literature. From these entirely noninvasive measures, we calculated mixed venous oxygen saturation and maximal tissue oxygen diffusing capacity.

Comparison of the single breath with the intrabreath method for the measurement of the carbon monoxide transfer factor in subjects with and without airways obstruction

BACKGROUND

Measurement of the carbon monoxide transfer factor (TLCO) has traditionally been performed using the single breath method but recently the intrabreath method has been developed. The aim of this study was to compare the two methods in the clinical evaluation of patients with obstructive and non-obstructive pulmonary disorders.

METHODS

Measurements of TLCO with the intrabreath method were carried out on a study sample composed of 50 patients with non-obstructive disorders and 50 with airways obstruction (FEV1/FVC < 70%) either before or after a single breath measurement of the TLCO had been performed. The method involves the continuous analysis of a single slow expirate using a computerised rapid multigas infrared analyser. TLCO, alveolar volume (VA), TLCO/VA, and inspired vital capacity (IVC) values were obtained for both groups by both methods.

RESULTS

When measured with the intrabreath method the group with airways obstruction showed lower TLCO and TLCO/VA values than the non-obstructive group. VA was higher in both patient groups when measured with the intrabreath technique. The same test also showed higher TLCO values with the intrabreath method in the group with non-obstructive disorders and lower TLCO/VA values with the intrabreath method in those with airways obstruction. The corresponding parameters obtained by the two methods correlated closely, with no correlation between the magnitude of the differences with the magnitude of the readings. An index of gas mixing indicated a better distribution of the inspired air for the intrabreath method than for the single breath method. The VA values obtained with the intrabreath method showed a closer agreement to the actual total lung capacities measured by body plethysmography.

CONCLUSION

The intrabreath method of determining TLCO is comparable to the traditional single breath method. Measurement of alveolar volume by the intrabreath method approximates more closely to total lung capacity, even in subjects with airways obstruction.

Determination of DLCO and cardiac output from expired gas slopes with cardiogenic oscillations

Effects of 'cardiogenic oscillations' on alveolar plateau gas concentration slope measurements, constant expiratory pulmonary capillary blood flow, and DLCO determination have not been previously described. We examined cardiogenic oscillations during constant expiratory maneuvers to assess factors influencing magnitude of oscillations as well as effect of oscillatory phase at the start and end of exhalation measurement period on alveolar gas slope. Five normal volunteers performed repeated single breath constant exhalation vital capacity maneuvers using test gas containing 2 physiologically 'inert' gases: Helium (He Mw 4) and argon (Ar Mw 40). The mixture contained 3 absorbable gases, acetylene (C2H2 Mw 26), carbon monoxide (C18O Mw 30), and oxygen. Alveolar plateau slope, magnitude of cardiogenic oscillations, relative signal to noise ratios, and effect of cardiogenic oscillation phase on measured slope were determined for each gas. Cardiogenic oscillations were present for all inert gases. Oscillations were less evident for CO. However, the effects on calculated Qc and DLCO were negligible. Cardiac oscillations of considerable magnitude are seen during single breath constant exhalation maneuvers and affect constant expiratory gas slope calculations. Cardiogenic oscillation phase does not have a significant effect on measured Qc and DLCO using constant expiratory techniques.

Measurement of transfer factor during constant exhalation

BACKGROUND

Transfer factor of the lung for carbon monoxide (TLCO) was measured by a new method based on analysis of the ratio of the concentrations of carbon monoxide to an inert gas (methane) relative to lung volume during a constant exhalation. Since this new technique is based solely upon exhalation, anomalies associated with inspiration and breath holding do not affect results. Additionally, because prolonged breath holding is not required, measurements can readily be made in dyspnoeic patients.

METHODS

Exhalation TLCO (TLCO,ex) was compared with the standard (Jones and Meade) 10 second breath holding TLCO (TLCO,bh) in 100 consecutive patients. Patients did not practise the exhalation manoeuvre prior to testing.

RESULTS

The comparative results were very close; mean difference (bias) +/- standard deviation (precision) was 0.05 (0.84) mmol/min/kPa. The relation was equally strong in patients with severe pulmonary disease; for patients with FEV1 < 1.51 the mean difference was 0.21 (0.80) mmol/min/kPa.

CONCLUSIONS

Since the results were essentially identical between the techniques, it seems that comparable pathophysiological factors affect TLCO during breath holding and constant exhalation. Constant exhalation may therefore be a useful alternative to the breath holding technique for clinical measurement of TLCO.

Normal values for single exhalation diffusing capacity and pulmonary capillary blood flow in sitting, supine positions, and during mild exercise

Previous approaches to the measurements of pulmonary diffusing capacity (DL) and pulmonary capillary blood flow (QC) utilized either the rebreathing or the single inhalation technique in conjunction with radioisotope gas and mass spectrometry. In the present study, we utilized a newly developed rapid infrared analyzer in conjunction with the slow single exhalation technique on 100 healthy volunteers to establish normal values for DL and QC under sitting, supine, and exercise conditions. The exercise level was determined by a target heart rate: HRex = ([HRmax - HRrest]/3) + HRrest. Prediction equations based on regressions on age, sex, height, or weight were then computed for sitting, supine, and exercise values. We found that mean DL and QC increased by approximately 12 percent and 8 percent, respectively, from sitting to supine posture, and by approximately 30 percent and 100 percent, respectively, from sitting (rest) to mild exercise. These results provided a database for further studies in the single exhalation method in various clinical settings.

Measurement of cardiac output by automated single-breath technique, and comparison with thermodilution and Fick methods in patients with cardiac disease

Accurate noninvasive methods are needed for determination of cardiac output. Current methods are generally complex or may be unreliable. A previously described method, based on absorption of acetylene gas during a constant exhalation that enables calculation of cardiac output by estimating pulmonary capillary circulation, is incorporated in a new, automated commercial product (SensorMedics 2200). In this study, cardiac output by single-breath acetylene blood flow measured with this device was compared with the standard thermodilution and direct Fick methods in 20 patients undergoing cardiac or pulmonary artery catheterization. Patients inhaled test gas mixture to total lung capacity and exhaled at a constant rate through an adjustable resistor. Lung volumes and noninvasive acetylene blood flow value were calculated automatically. Correlation between the automated single-breath technique and both thermodilution and Fick cardiac output determinations was very high (correlation coefficients were 0.90 and 0.92, respectively), regression slopes were close to identity (0.98 and 0.90), and bias (-0.39 and -0.79 liter/min) and precision (0.94 and 1.02) were good; when shunt correction was applied, bias was reduced to 0.06 and 0.35 liter/min, respectively. Rapid, accurate, noninvasive measurement of cardiac output was easily obtained using the automated device. This technique may have a wide applicability for noninvasive evaluation of patients with cardiac disease and for monitoring effects of therapeutic interventions.

An extended soluble gas exchange model for estimating pulmonary perfusion--I: Derivation and implementation

A dynamic model for respiratory exchange of blood soluble gas is described. This model includes a general treatment of tidal breathing, an inhomogeneous lung comprising multiple distensible compartments, and nonlinearities due to multiple-gas effects. The motivation for this new model is the continuing interest in estimating pulmonary perfusion from measurements of respiratory soluble gas exchange. Numerical simulation can be employed to investigate the errors that result from simplifications made in the derivations of simpler models used for this purpose. Examples of such simplifications are the assumptions that ventilation is constant and unidirectional, and that multiple soluble gases can be independently modeled. These results can delimit the boundaries within which perfusion estimates can be considered reliable. An example demonstrating the model and its numerical solution is presented.

Non-invasive measurement of cardiac output by a single breath constant expiratory technique

A new single breath test has been developed that measures pulmonary blood flow (Qc) and pulmonary tissue volume by using the fact that Qc is proportional to the relationship between the absorption rate of acetylene (C2H2) from the alveolar gas and the rate of change of lung volume during constant expiratory flow. To make these measurements a bag in bottle system with a rolling seal spirometer, a mass spectrometer, and a minicomputer with analogue to digital conversion have been used. Qc was compared with cardiac output measured by the thermodilution technique in 20 patients with cardiac disease; some also had mild chronic obstructive pulmonary disease. The mean (SD) resting Qc for the group was 5.27 (1.22) l/min and the cardiac output measured by thermodilution was 5.30 (1.31) l/min. The mean difference between the two estimations of cardiac output was 0.03 l and the standard deviation of this difference was 0.76 l. The Qc technique was not successful in patients with an FEV1/FVC less than 60%, but seemed to be accurate in those with higher FEV1/FVC values. Correction of Qc for the effect of venous admixture in 14 patients resulted in an average 19% overestimation of cardiac output (6.01 (2.52) l/min v 5.05 (1.64) l/min). It is concluded that cardiac output can be accurately measured in patients with cardiac or mild pulmonary disease. No correction for venous admixture due to ventilation-perfusion mismatch was necessary in these patients, presumably because the large breath used by the technique overcomes most mild ventilation-perfusion maldistribution. These findings, in addition to the non-invasive nature of the technique, suggest potential value for the measurement of cardiac output in various clinical conditions.