Determinants of pulmonary blood volume. Effects of acute changes in pulmonary vascular pressures and flow

Measurement of pulmonary edema in patients with acute respiratory distress syndrome*

OBJECTIVE

We measured pulmonary edema by thermal indocyanine green-dye double-dilution technique and quantitative computed tomography (CT) in patients with acute respiratory distress syndrome and compared the two techniques.

DESIGN AND SETTING

Prospective human study in a university hospital.

PATIENTS

Fourteen mechanically ventilated patients with acute respiratory distress syndrome (nine primary; nine with intubation <7 days).

INTERVENTIONS

All patients underwent a spiral CT of the thorax. We measured pulmonary thermal volume (PTV) and its components, extravascular lung water and pulmonary blood volume, with an integrated fiberoptic monitoring system (COLD Z-021).

MEASUREMENTS AND RESULTS

PTV was tightly correlated with lung weight (LW) measured by CT (PTV = 0.6875 * LW(CT) + 292.77; correlation coefficient = 0.91; p < .0001; bias -11 +/- 8 %). Neither etiology of acute respiratory distress syndrome (primary vs. secondary) nor days of intubation affected the accuracy of thermal dye dilution in comparison with CT. There was no correlation between the extravascular lung water (12.3 +/- 3.4 mL/kg) and CT distribution of lung tissue compartments. Extravascular lung water and pulmonary blood volume showed good reproducibility in 32 pairs of thermal dye dilution measurements.

CONCLUSIONS

Measurements of lung edema by thermal indocyanine green-dye double-dilution method show good correlation with those by quantitative computed tomography and good reproducibility in patients with acute respiratory distress syndrome.

Intrapulmonary shunt after cardiopulmonary bypass: the use of vital capacity maneuvers versus off-pump coronary artery bypass grafting

OBJECTIVES

It has been proved in human subjects and animals that atelectasis is a major cause of intrapulmonary shunting and hypoxemia after cardiopulmonary bypass. Animal studies suggest that shunting can be prevented entirely by a total vital capacity maneuver performed before termination of bypass. This study aimed to test this theory in human subjects and to evaluate possible advantages of off-pump coronary artery bypass grafting.

METHODS

Twenty-four patients scheduled for coronary artery bypass grafting were randomly assigned to receive no total vital capacity maneuver (control group, n = 12) or standard total vital capacity maneuvers (TVCM group, n = 12). Additionally, 12 consecutive patients undergoing off-pump coronary artery bypass grafting (off-pump group) were studied. Systemic and central hemodynamics, the pattern of breathing, and ventilatory mechanics were evaluated after induction of anesthesia, after sternotomy, after cardiopulmonary bypass and skin closure, and 4 hours after extubation.

RESULTS

The use of total vital capacity maneuvers reduced (P <.05) intrapulmonary shunting after termination of cardiopulmonary bypass. However, shunting increased (P <.05) in all groups (control group, 8.2% +/- 3.3% vs 25.6% +/- 8.1%; TVCM group, 8.7% +/- 3.4% vs 24.4% +/- 8.5%; and off-pump group, 7.8% +/- 2.8% vs 14.0% +/- 5.3%) after extubation, but the increase was significantly (P <.05) less pronounced in the off-pump group. Furthermore, pulmonary compliance decreased (P <.05) in all groups except the off-pump group after extubation. Duration of hospital and intensive care unit stay was significantly shorter (P <.05) in the off-pump group than in the other groups.

CONCLUSION

The development of intrapulmonary shunting and hypoxemia after coronary artery bypass grafting can be substantially reduced by performance of total vital capacity maneuvers while patients are mechanically ventilated. However, off-pump coronary artery bypass surgery is superior in preventing shunting and hypoxemia after bypass grafting in the immediate and early postoperative periods, probably leading to substantially shorter intensive care unit and hospital stays.

The effects of beta-blockade on electrically stimulated contraction in fatigued human triceps surae muscle

The contractile characteristics of the triceps surae muscle group were examined before and after repeated isometric contractions in two groups of eight healthy young males. Single twitches and trains of stimuli at 10, 20, 50 and 100 Hz were delivered to the muscle using supramaximal voltages. Subjects were treated with beta-blockade (2 X 80 mg oral propranolol, beta-b) or matched placebo in a double-blind crossover design. Four different exercise conditions were studied: (I) maximal voluntary contraction (MVC); (II) MVC during circulatory occlusion; (III) electrical stimulation at 20 Hz using 50% of voltage required for maximal torque production; and (IV) electrical stimulation with occlusion. Each contraction was for 5 s with 5 s recovery. Total duration of exercise was 10 min for non-occluded contractions and to a 50% decline in torque output with occlusion. At rest prior to exercise, maximal voluntary contraction was significantly reduced (5.7%) by beta-b during 40 observations in 16 subjects. Following exercise without occlusion (I and III), the reduction in torque output of the muscle at 10 and 20 Hz stimulation was generally greater during beta-b than placebo. This low frequency fatigue was longer-lasting with beta-b. The shorter lasting reduction in torque at 50 and 100 Hz was generally not different between beta-b placebo. After exercise with occlusion (II and IV), the torque output at all stimulation frequencies was reduced to a similar extent in both placebo and beta-b at most comparison points. Twitch responses after exercise with occlusion showed decreases in peak tension and time to peak tension and a lengthening of one-half relaxation time in both placebo and beta-b. It was concluded that the greater reduction in torque output of the triceps surae muscle group at low frequencies during beta-b was probably a consequence of a reduction in blood flow relative to the placebo treatment. This relative low frequency fatigue could be responsible for the increased perception of effort in patients exercising during beta-blocker therapy.

Acute alveolar hypoxia increases bronchopulmonary shunt flow in the dog

To study the effects of alveolar hypoxia on canine bronchopulmonary shunt flow, a biventricular bypass preparation was employed. The preparation allowed a constant and sensitive measure of changes in pulmonary venous blood flow. In 16 of 18 dogs with intact bronchial arteries, alveolar hypoxia caused an increase in pulmonary venous return both under conditions of constant pulmonary arterial inflow and under conditions of no pulmonary arterial inflow, suggesting bronchopulmonary shunting. This effect was accompanied by systemic vasodilation despite vagotomy and ganglionic blockade, and was abolished by division of all bronchial vessels. Ibuprofen, 3 mg/kg, and indomethacin, 15 mg/kg, in dogs with intact bronchial vessels, abolished both the increase in pulmonary venous return and the systemic vasodilatation caused by hypoxia. Thus, alveolar hypoxia directly augments bronchopulmonary flow, most likely through release of one or more vasodilating prostaglandins.

Determinants of pulmonary blood volume. Effects of acute changes in airway pressure

To examine the effects of airway pressure (AWP) on pulmonary blood volume (PBV) at various pulmonary vascular pressures and flows, experiments were performed in anaesthetized, open-chest dogs. The AWP was raised by elevating end-expiratory pressure, and PBV was calculated as the product of electromagnetic aortic flow and pulmonary mean transit time for ascorbate (polarographic method). When AWP was raised from 3 to 13 mmHg, changing lung conditions from zone 3 [left atrial pressure (LAP) higher than AWP] to zone 2 (AWP higher than LAP), PBV decreased by 14.5 +/- 6.2%. When LAP was raised above 7 mmHg at constant pulmonary arterial pressure (PAP), PBV increased under zone 2 but not under zone 3 conditions. During blood volume expansion to LAP 15 mmHg, PBV rose by 30-50% and became equal at AWP of 4 and 14 mmHg, whereas the pulmonary vascular resistance remained 40% higher at high AWP. These data suggest that PAP, LAP and AWP regulate PBV by acting on compliant vessels surrounding the alveoli. Under zone 2 conditions with collapsed aveolar capillaries, elevation of LAP results in re-expansion of the alveolar capillaries, and PBV is restored without a rise in PAP. Under zone 3 conditions, a rise in LAP cannot increase PBV without raising PAP, explaining why PBV remains constant when PAP is kept constant.