Pulmonary blood flow measured by inspiratory inert gas concentration forcing oscillations

Noninvasive cardiac output monitoring in a porcine model using the inspired sinewave technique: a proof-of-concept study

Background

Cardiac output (Q˙) monitoring can support the management of high-risk surgical patients, but the pulmonary artery catheterisation required by the current ‘gold standard’—bolus thermodilution (Q˙T)—has the potential to cause life-threatening complications. We present a novel noninvasive and fully automated method that uses the inspired sinewave technique to continuously monitor cardiac output (Q˙IST).

Methods

Over successive breaths the inspired nitrous oxide (N₂O) concentration was forced to oscillate sinusoidally with a fixed mean (4%), amplitude (3%), and period (60 s). Q˙IST was determined in a single-compartment tidal ventilation lung model that used the resulting amplitude/phase of the expired N₂O sinewave. The agreement and trending ability of Q˙IST were compared with Q˙T during pharmacologically induced haemodynamic changes, before and after repeated lung lavages, in eight anaesthetised pigs.

Results

Before lung lavage, changes in Q˙IST and Q˙T from baseline had a mean bias of –0.52 L min⁻¹ (95% confidence interval [CI], –0.41 to –0.63). The concordance between Q˙IST and Q˙T was 92.5% as assessed by four-quadrant analysis, and polar plot analysis revealed a mean angular bias of 5.98° (95% CI, –24.4°–36.3°). After lung lavage, concordance was slightly reduced (89.4%), and the mean angular bias widened to 21.8° (–4.2°, 47.6°). Impaired trending ability correlated with shunt fraction (r=0.79, P<0.05).

Conclusions

The inspired sinewave technique provides continuous and noninvasive monitoring of cardiac output, with a ‘marginal–good’ trending ability compared with cardiac output based on thermodilution. However, the trending ability can be reduced with increasing shunt fraction, such as in acute lung injury.

The inspired sine-wave technique: A novel method to measure lung volume and ventilatory heterogeneity

NEW FINDINGS

What is the central question of this study? We present a new non-invasive medical technology, the inspired sine-wave technique, which involves inhalation of sinusoidally fluctuating concentrations of a tracer gas. The technique requires only passive patient cooperation and can monitor different cardiorespiratory variables, such as end-expired lung volume, ventilatory heterogeneity and pulmonary blood flow. What is the main finding and its importance? In this article, we demonstrate that the measurements of end-expired lung volume are repeatable and accurate, in comparison to whole-body plethysmography, and the technique is sensitive to the changes in ventilatory heterogeneity associated with advancing age. As such, it has the potential to provide clinically valuable information.

ABSTRACT

The inspired sine-wave technique (IST) is a new method that can provide simple, non-invasive cardiopulmonary measurements. Over successive tidal breaths, the concentration of a tracer gas (i.e. nitrous oxide, N₂ O) is sinusoidally modulated in inspired air. Using a single-compartment tidal-ventilation lung model, the resulting amplitude/phase of the expired sine wave allows estimation of end-expired lung volume (ELV), pulmonary blood flow and three indices for ventilatory heterogeneity (VH; ELV₁₈₀ /FRC_pleth , ELV₁₈₀ /FRC_pred and ELV₆₀ /ELV₁₈₀ ). This investigation aimed to determine the repeatability and agreement of ELV with FRC_pleth and, as normal ageing results in well-established changes in pulmonary structure and function, whether the IST estimates of ELV and VH are age dependent. Forty-eight healthy never-smoker participants (20-86 years) underwent traditional pulmonary function testing (e.g. spirometry, body plethysmography) and the IST test, which consisted of 4 min of quiet breathing through a face mask while inspired N₂ O concentrations were oscillated in a sine-wave pattern with a fixed mean (4%) and amplitude (3%) and a period of either 180 or 60 s. The ELV₁₈₀ /FRC_pleth and ELV₁₈₀ /FRC_pred were age dependent (average decreases of 0.58 and 0.48% year^-1 ), suggesting an increase in VH with advancing age. The ELV showed a mean bias of -1.09 litres versus FRC_pleth , but when normalized for the effects of age this bias reduced to -0.35 litres. The IST test has potential to provide clinically useful information necessitating further study (e.g. for mechanically ventilated or obstructive lung disease patients), but these findings suggest that the increases in VH with healthy ageing must be taken into account in clinical investigations.

The Inspired Sinewave Technique: A Comparison Study With Body Plethysmography in Healthy Volunteers

The inspired sinewave technique is a noninvasive method to measure airway dead space, functional residual capacity, pulmonary blood flow, and lung inhomogeneity simultaneously. The purpose of this paper was to assess the repeatability and accuracy of the current device prototype in measuring functional residual capacity, and also participant comfort when using such a device. To assess within-session repeatability, six sinewave measurements were taken over two-hour period in 17 healthy volunteers. To assess day-to-day repeatability, measurements were taken over 16 days in 3 volunteers. To assess accuracy, sinewave measurements were compared to body plethysmography in 44 healthy volunteers. Finally, 18 volunteers who experienced the inspired sinewave device, body plethysmography and spirometry were asked to rate the comfort of each technique on a scale of 1–10. The repeatability coefficients for dead space, functional residual capacity, and blood flow were 48.7 ml, 0.48L, and 2.4L/min respectively. Bland-Altman analyses showed a mean BIAS(SD) of −0.68(0.42)L for functional residual capacity when compared with body plethysmography. 14 out of 18 volunteers rated the inspired sinewave device as their preferred technique. The repeatability and accuracy of functional residual capacity measurements were found to be as good as other techniques in the literature. The high level of comfort and the non-requirement of patient effort meant that, if further refined, the inspired sinewave technique could be an attractive solution for difficult patient groups such as very young children, elderly, and ventilated patients.

Assessment of lung function using a non-invasive oscillating gas-forcing technique

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We propose a compact and non-invasive system for the measurement and monitoring of lung function.

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We develop a novel tidal ventilation model using a non-invasive oscillating gas-forcing technique.

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We compare a conventional continuous ventilation model with the proposed tidal ventilation model.

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The proposed technique has several advantages over conventional methods, and can be used to assess patient lung function.

Conventional methods for monitoring lung function can require complex, or special, gas analysers, and may therefore not be practical in clinical areas such as the intensive care unit (ICU) or operating theatre. The system proposed in this article is a compact and non-invasive system for the measurement and monitoring of lung variables, such as alveolar volume, airway dead space, and pulmonary blood flow. In contrast with conventional methods, the compact apparatus and non-invasive nature of the proposed method could eventually allow it to be used in the ICU, as well as in general clinical settings. We also propose a novel tidal ventilation model using a non-invasive oscillating gas-forcing technique, where both nitrous oxide and oxygen are used as indicator gases. Experimental results are obtained from healthy volunteers, and are compared with those obtained using a conventional continuous ventilation model. Our findings show that the proposed technique can be used to assess lung function, and has several advantages over conventional methods such as compact and portable apparatus, easy usage, and quick estimation of cardiopulmonary variables.

The effect of diffusion in the respiratory tree on the alveolar amplitude response technique (AART)

Theoretical data for the alveolar amplitude response technique (AART) (J. Appl. Physiol. 41 (1976) 419-424) for assessing lung function was simulated using a single path lung model. This model takes account of stratified inhomogeneities in gas concentrations within the respiratory tree. The data was inserted into previously published parameter recovery techniques that may be used to estimate dead-space volume, alveolar volume and cardiac output. These parameter recovery techniques are based on much simpler mathematical models that do not allow stratified inhomogeneities in gas concentrations. It was found that: (i) recovered dead-space volume depended significantly on the ventilation pattern and on the distribution of volume within of the conducting airways; (ii) alveolar volume was recovered to a good degree of accuracy; and (iii) the recovered value of cardiac output was highly dependent on both the choice of inert gas and parameter recovery technique.

A tidal breathing model of the inert gas sinewave technique for inhomogeneous lungs

The tidal breathing model conservation of mass equations for the sinewave technique have been described for a homogeneous alveolar compartment by Gavaghan and Hahn, 1996 [Gavaghan, D.J., Hahn, C.E.W., 1996. A tidal breathing model of the forced inspired gas sinewave technique. Respir. Physiol. 106, 209-221]. We develop these equations first to a multi-discrete alveolar compartment lung model and then to a lung model with a continuous distribution of volume, ventilation and perfusion. The effect on the output parameters of a multi-compartment model is discussed, and the results are compared to those derived from the conventional continuous-ventilation model. Using the barely soluble gas argon as the tracer gas, an empirical index of alveolar inhomogeneity is presented which uses the end-expired and mixed-expired partial pressures on each breath. This index distinguishes between a narrow unimodal distribution of ventilation-volume, a wide unimodal distribution of ventilation-volume and a bimodal distribution of ventilation-volume. By using Monte Carlo simulations, this index is shown to be stable to experimental error of realistic magnitude.

Modelling inert gas exchange in tissue and mixed-venous blood return to the lungs

Inert gas exchange in tissue has been almost exclusively modelled by using an ordinary differential equation. The mathematical model that is used to derive this ordinary differential equation assumes that the partial pressure of an inert gas (which is proportional to the content of that gas) is a function only of time. This mathematical model does not allow for spatial variations in inert gas partial pressure. This model is also dependent only on the ratio of blood flow to tissue volume, and so does not take account of the shape of the body compartment or of the density of the capillaries that supply blood to this tissue. The partial pressure of a given inert gas in mixed-venous blood flowing back to the lungs is calculated from this ordinary differential equation. In this study, we write down the partial differential equations that allow for spatial as well as temporal variations in inert gas partial pressure in tissue. We then solve these partial differential equations and compare them to the solution of the ordinary differential equations described above. It is found that the solution of the ordinary differential equation is very different from the solution of the partial differential equation, and so the ordinary differential equation should not be used if an accurate calculation of inert gas transport to tissue is required. Further, the solution of the PDE is dependent on the shape of the body compartment and on the density of the capillaries that supply blood to this tissue. As a result, techniques that are based on the ordinary differential equation to calculate the mixed-venous blood partial pressure may be in error.

A method of reconstruction of clinical gas-analyzer signals corrupted by positive-pressure ventilation

The use of sidestream infrared and paramagnetic clinical gas analyzers is widespread in anesthesiology and respiratory medicine. For most clinical applications, these instruments are entirely satisfactory. However, their ability to measure breath-by-breath volumetric gas fluxes, as required for measurement of airway dead space, oxygen uptake, and so on, is usually inferior to that of the mass spectrometer, and this is thought to be due, in part, to their slower response times. We describe how volumetric gas analysis with the Datex Ultima analyzer, although reasonably accurate for spontaneous ventilation, gives very inaccurate results in conditions of positive-pressure ventilation. We show that this problem is a property of the gas sampling system rather than the technique of gas analysis itself. We examine the source of this error and describe how cyclic changes in airway pressure result in variations in the flow rate of the gas within the sampling catheter. This results in the phenomenon of "time distortion," and the resultant gas concentration signal becomes a nonlinear time series. This corrupted signal cannot be aligned or integrated with the measured flow signal. We describe a method to correct for this effect. With the use of this method, measurements required for breath-by-breath gas-exchange models can be made easily and reliably in the clinical setting.

Response-time enhancement of a clinical gas analyzer facilitates measurement of breath-by-breath gas exchange

Tidal ventilation gas-exchange models in respiratory physiology and medicine not only require solution of mass balance equations breath-by-breath but also may require within-breath measurements, which are instantaneous functions of time. This demands a degree of temporal resolution and fidelity of integration of gas flow and concentration signals that cannot be provided by most clinical gas analyzers because of their slow response times. We have characterized the step responses of the Datex Ultima (Datex Instrumentation, Helsinki, Finland) gas analyzer to oxygen, carbon dioxide, and nitrous oxide in terms of a Gompertz four-parameter sigmoidal function. By inversion of this function, we were able to reduce the rise times for all these gases almost fivefold, and, by its application to real on-line respiratory gas signals, it is possible to achieve a performance comparable to the fastest mass spectrometers. With the use of this technique, measurements required for non-steady-state and tidal gas-exchange models can be made easily and reliably in the clinical setting.