End-expiratory lung impedance change enables bedside monitoring of end-expiratory lung volume change

OBJECTIVE

The aim of the study was to investigate the effect of lung volume changes on end-expiratory lung impedance change (ELIC) in mechanically ventilated patients, since we hypothesized that ELIC may be a suitable parameter to monitor lung volume change at the bedside.

DESIGN

Clinical trial on patients requiring mechanical ventilation.

SETTINGS

Intensive care units of a university hospital.

PATIENTS

Ten mechanically ventilated patients were included in the study.

INTERVENTION

Patients were ventilated in volume-controlled mode with constant flow and respiratory rate. In order to induce changes in the end-expiratory lung volume (EELV), PEEP levels were increased from 0 mbar to 5 mbar, 10 mbar, and 15 mbar. At each PEEP level EELV was measured by an open-circuit nitrogen washout manoeuvre and ELIC was measured simultaneously using Electrical Impedance Tomography (EIT) with sixteen electrodes placed on the circumference of the thorax and connected with an EIT device. Cross-sectional electro-tomographic measurements of the thorax were performed at each PEEP level, and a modified Sheffield back-projection was used to reconstruct images of the lung impedance. ELIC was calculated as the average of the end-expiratory lung impedance change. RESULTS. Increasing PEEP stepwise from 0 mbar to 15 mbar resulted in an linear increase of EELV and ELIC according to the equation: y =0.98 x -0.68, r(2)=0.95.

CONCLUSION

EIT is a simple bedside technique which enables monitor lung volume changes during ventilatory manoeuvres such as PEEP changes.

Gravity effects on regional lung ventilation determined by functional EIT during parabolic flights

Gravity-dependent changes of regional lung function were studied during normogravity, hypergravity, and microgravity induced by parabolic flights. Seven healthy subjects were followed in the right lateral and supine postures during tidal breathing, forced vital capacity, and slow expiratory vital capacity maneuvers. Regional 1) lung ventilation, 2) lung volumes, and 3) lung emptying behavior were studied in a transverse thoracic plane by functional electrical impedance tomography (EIT). The results showed gravity-dependent changes of regional lung ventilation parameters. A significant effect of gravity on regional functional residual capacity with a rapid lung volume redistribution during the gravity transition phases was established. The most homogeneous functional residual capacity distribution was found at microgravity. During vital capacity and forced vital capacity in the right lateral posture, the decrease in lung volume on expiration was larger in the right lung region at all gravity phases. During tidal breathing, the differences in ventilation magnitudes between the right and left lung regions were not significant in either posture or gravity phase. A significant nonlinearity of lung emptying was determined at normogravity and hypergravity. The pattern of lung emptying was homogeneous during microgravity.

Imaging pathologic pulmonary air and fluid accumulation by functional and absolute EIT

The increasing use of EIT in clinical research on severely ill lung patients requires a clarification of the influence of pathologic impedance distributions on the validity of the resulting tomograms. Significant accumulation of low-conducting air (e.g. pneumothorax or emphysema) or well-conducting liquid (e.g. haematothorax or atelectases) may conflict with treating the imaging problem as purely linear. First, we investigated the influence of stepwise inflation and deflation by up to 300 ml of air and 300 ml of Ringer solution into the pleural space of five pigs on the resulting tomograms during ventilation at constant tidal volume. Series of EIT images representing relative impedance changes were generated on the basis of a modified Sheffield back projection algorithm and ventilation distribution was displayed as functional (f-EIT) tomograms. In addition, a modified simultaneous iterative reconstruction technique (SIRT) was applied to quantify the resistivity distribution on an absolute level scaled in Omega m (a-EIT). Second, we applied these two EIT techniques on four intensive care patients with inhomogeneous air and fluid distribution and compared the EIT results to computed tomography (CT) and to a reference set of intrathoracic resistivity data of 20 healthy volunteers calculated by SIRT. The results of the animal model show that f-EIT based on back projection is not disturbed by the artificial pneumo- or haematothorax. Application of SIRT allows reliable discrimination and detection of the location and amplitude of pneumo- or haematothorax. These results were supported by the good agreement between the electrical impedance tomograms and CT scans on patients and by the significant differences of regional resistivity data between patients and healthy volunteers.

Regional filling characteristics of the lungs in mechanically ventilated patients with acute lung injury

OBJECTIVES

The objective of the study was to determine regional pulmonary filling characteristics in 20 mechanically ventilated patients with acute lung injury.

METHODS

Regional filling characteristics were calculated from tracings of regional tidal volumes vs. global tidal volumes measured by electrical impedance tomography (EIT). These plots were fitted to a polynomial function of the second degree. Regional polynomial coefficients of the second degree characterized the curve linearity of the plots. Near-zero values of the polynomial coefficient indicated a homogeneous increase in regional tidal volumes during the whole inspiration. Positive values hinted at initial low regional tidal volume change suggesting lung volume recruitment. Negative values indicated late low regional tidal volume change implying hyperinflation of this lung region.

RESULTS

We found a broad heterogeneity of regional lung filling characteristics. The minimal regional polynomial coefficients varied from -2.80 to -0.56 (median -1.16), while the maximal regional polynomial coefficients varied from 0.58 to 3.65 (median 1.41).

CONCLUSIONS

Measurements of regional filling characteristics by EIT may be a helpful tool to adjust the respiratory settings during mechanical ventilation to optimize lung recruitment and to avoid overdistension. It applies a non-pressure-related assessment to the mechanics of lung inflation and gives a view of the real problems underlying ventilatory strategies dependent on global characteristics.

Regional pulmonary pressure volume curves in mechanically ventilated patients with acute respiratory failure measured by electrical impedance tomography

BACKGROUND

We hypothesized, that in mechanically ventilated patients with acute respiratory failure, regional pressure volume curves differ markedly from conventional global pressure volume curves of the whole lung.

METHODS

In nine mechanically ventilated patients with acute respiratory failure during an inspiratory low-flow manoeuvre, conventional global pressure volume curves were registered by spirometry and regional pressure volume curves in up to 912 regions were assessed simultaneously using electrical impedance tomography. We compared the lower (LIP) and upper (UIP) inflection points obtained from the conventional global pressure volume curve and regional pressure volume curves.

RESULTS

We identified from the conventional global pressure volume curves LIP [3-11 (8) cmH2O] in eight patients and UIP [31-39 (33) cmH2O] in three patients. Using electrical impedance tomography (EIT), LIP [3-18 (8) cmH2O] in 54-264 (180) regions and UIP [23-42 (36) cmH2O] in 149-324 (193) regions (range and median) were identified. Lung mechanics measured by conventional global pressure volume curves are similar to the median of regional pressure volume curves obtained by EIT within the tomographic plane. However, single regional pressure volume curves differ markedly with a broad heterogeneity of lower and upper inflection points.

CONCLUSION

Lower and upper inflection points obtained from conventional global pressure volume curves are not representative of all regions of the lungs.

Rationale for and results from a randomised, double-blind trial of tetrachlorodecaoxygen anion complex in wound healing

Local tetrachlorodecaoxygen anion complex (TCDO) had three therapeutic effects in difficult wounds, substantiated on day 14 in a multicentre double-blind randomised clinical trial on 271 inpatients with 0.9% saline as control. Wound cleansing was intensified, the formation of new tissue (granulations, epithelium) was promoted, and, irrespective of the different wound types, wound surfaces decreased more quickly, by a factor of 2.4. A novel quantity (eta) was derived as an indicator of wound healing promotion. eta NaCl (= -0.14) did not differ among different wound diagnoses. eta TCDO values were significantly better in relation to wound diagnosis, to smear (detritus), and to epithelialisation. Local TCDO was well tolerated.

A new inactivated tissue culture rabies vaccine for use in man. Evaluation of PCEC-vaccine by laboratory tests

A new inactivated rabies vaccine (purified chick embryo cell vaccine) has been developed using the Flury LEP-C 25 strain of rabies virus propagated in primary chick embryo cell cultures. The antigen was purified and concentrated by continuous density gradient centrifugation and inactivated by betapropiolactone. This vaccine was tested for innocuity, tolerability and protective capacity in a series of laboratory tests and compared with human diploid cell strain (HDC)-vaccines of similar antigenicity. The results indicated that this new vaccine was excellently tolerated and that its protective activity met the high standard of HDC-vaccine, conditions which were imposed on this vaccine before entering clinical trials in man.

Selective processing of all rotational and translational optic flow directions in the zebrafish pretectum and tectum

Background

The processing of optic flow in the pretectum/accessory optic system allows animals to stabilize retinal images by executing compensatory optokinetic and optomotor behavior. The success of this behavior depends on the integration of information from both eyes to unequivocally identify all possible translational or rotational directions of motion. However, it is still unknown whether the precise direction of ego-motion is already identified in the zebrafish pretectum or later in downstream premotor areas.

Results

Here, we show that the zebrafish pretectum and tectum each contain four populations of motion-sensitive direction-selective (DS) neurons, with each population encoding a different preferred direction upon monocular stimulation. In contrast, binocular stimulation revealed the existence of pretectal and tectal neurons that are specifically tuned to only one of the many possible combinations of monocular motion, suggesting that further downstream sensory processing might not be needed to instruct appropriate optokinetic and optomotor behavior.

Conclusion

Our results suggest that local, task-specific pretectal circuits process DS retinal inputs and carry out the binocular sensory computations necessary for optokinetic and optomotor behavior.

Electronic supplementary material

The online version of this article (10.1186/s12915-019-0648-2) contains supplementary material, which is available to authorized users.

Determination of functional residual capacity (FRC) by multibreath nitrogen washout in a lung model and in mechanically ventilated patients. Accuracy depends on continuous dynamic compensation for changes of gas sampling delay time

OBJECTIVE

Validation of an open-circuit multibreath nitrogen washout technique (MBNW) for measurement of functional residual capacity (FRC). The accuracy of FRC measurement with and without continuous viscosity correction of mass spectrometer delay time (TD) relative to gas flow signal and the influence of baseline FIO2 was investigated.

DESIGN

Laboratory study and measurements in mechanically ventilated patients.

SETTING

Experimental laboratory and anesthesiological intensive care unit of a university hospital.

PATIENTS

16 postoperative patients with normal pulmonary function (NORM), 8 patients with acute lung injury (ALI) and 6 patients with chronic obstructive pulmonary disease (COPD) were included.

INTERVENTIONS

Change of FIO2 from baseline to 1.0.

MEASUREMENTS AND MAIN RESULTS

FRC was determined by MBNW using continuous viscosity correction of TD(TDdyn), a constant TD based on the viscosity of a calibration gas mixture (TD0) and a constant TD referring to the mean viscosity between onset and end of MBNW (TDmean). Using TDdyn, the mean deviation between 15 measurements of three different lung model FRCs (FRCmeasured) and absolute volumes (FRCmodel) was 0.2%. For baseline FIO2 ranging from 0.21 to 0.8, the mean deviation between FRCmeasured and FRCmodel was -0.8%. However, depending on baseline FIO2, the calculation of FRC using TDmean and TD0 increased the mean deviation between FRCmeasured and FRCmodel to 2-4% and 8-12%, respectively. In patients (n = 30) the average repeatability coefficient was 6.0%. FRC determinations with TDmean and TD0 were 0.8-13.3% and 4.2-23.9% (median 2.7% and 8.7%) smaller than those calculated with TDdyn.

CONCLUSION

A dynamic viscosity correction of TD improves the accuracy of FRC determinations by MBNW considerably, when gas concentrations are measured in a sidestream. If dynamic TD correction cannot be performed, the use of constant TDmean might be suitable. However, in patient measurements this can cause an FRC underestimation of up to 13%.

Parallel Channels for Motion Feature Extraction in the Pretectum and Tectum of Larval Zebrafish

Non-cortical visual areas in vertebrate brains extract relevant stimulus features, such as motion, object size, and location, to support diverse behavioral tasks. The optic tectum and pretectum, two primary visual areas in zebrafish, are involved in motion processing, and yet their differential neural representation of behaviorally relevant visual features is unclear. Here, we characterize receptive fields (RFs) of motion-sensitive neurons in the diencephalon and midbrain. We show that RFs of many pretectal neurons are large and sample the lower visual field, whereas RFs of tectal neurons are mostly small-size selective and sample the upper nasal visual field more densely. Furthermore, optomotor swimming can reliably be evoked by presenting forward motion in the lower temporal visual field alone, matching the lower visual field bias of the pretectum. Thus, tectum and pretectum extract different visual features from distinct regions of visual space, which is likely a result of their adaptations to hunting and optomotor behavior, respectively.

Effect of positive end-expiratory-pressure on regional ventilation in patients with acute lung injury evaluated by electrical impedance tomography

BACKGROUND AND OBJECTIVE

For the treatment of patients with adult respiratory distress syndrome and acute lung injury bedside measurements of regional lung ventilation should be considered for optimizing ventilatory settings. The aim was to investigate the effect of positive end-expiratory pressure (PEEP) on regional ventilation in mechanically ventilated patients at the bedside by electrical impedance tomography.

METHODS

Eight mechanically ventilated patients were included in the study. PEEP levels were increased from 0 to 5, 10, 15 mbar and back to 0 mbar. Regional ventilation in 912 regions of the thorax was investigated at each PEEP by electrical impedance tomography. The obtained regions were divided in four groups: none (none and poorly ventilated regions including chest wall and mediastinum), bad, moderate and well-ventilated regions.

RESULTS

Increasing the PEEP stepwise from 0 to 15 mbar decreased the non-ventilated regions (none: 540 regions at PEEP 0 and 406 regions at PEEP 15). In contrast, the other regions increased (bad: 316 regions at PEEP 0 and 380 regions at PEEP 15; moderate: 40 regions at PEEP 0 and 100 regions at PEEP 15; well: 0 region at PEEP 0 and 34 regions at PEEP 15 (median values)) indicating an improvement of regional ventilation.

CONCLUSIONS

Increasing PEEP in mechanically ventilated patients reduces none ventilated regions (atelectasis). Furthermore, it leads to a shift from none and bad ventilated regions to moderately and well-ventilated regions. Electrical impedance tomography is a bedside technique and might be an alternative to computed tomography scan to assess aerated lung regions.

A neuronal mechanism for motivational control of behavior

Acting to achieve goals depends on the ability to motivate specific behaviors based on their predicted consequences given an individual’s internal state. However, the underlying neuronal mechanisms that encode and maintain such specific motivational control of behavior are poorly understood. Here, we used Ca²⁺ imaging and optogenetic manipulations in the basolateral amygdala of freely moving mice performing noncued, self-paced instrumental goal-directed actions to receive and consume rewards. We found that distinct neuronal activity patterns sequentially represent the entire action-consumption behavioral sequence. Whereas action-associated patterns integrated the identity, value, and expectancy of pursued goals, consumption-associated patterns reflected the identity and value of experienced outcomes. Thus, the interplay between these patterns allows the maintenance of specific motivational states necessary to adaptively direct behavior toward prospective rewards.

CMV monitoring using blood cells and plasma: a comparison of apples with oranges?

Quantitative cytomegalovirus (CMV) monitoring is still far from being standardized between transplant centers. In the present study, we compared assays for quantitative CMV monitoring using blood cells and plasma. Four hundred and thirty-five consecutive samples from 29 patients with active CMV infection after allogeneic T-cell-depleted hemopoietic stem cell transplantation were tested in parallel using pp65 antigenemia and quantitative CMV polymerase chain reaction (PCR) in blood cells and plasma (COBAS AMPLICOR CMV MONITOR). Although only 142 (53.1%) of 253 positive samples were concordantly identified by all three assays, the number of positive samples detected by each assay was not different and the quantitative values were correlated, provided that nucleic acid (NA) in plasma was isolated by COBAS AmpliPrep and not by the manual protocol. Six (18%) of 34 episodes with active CMV infection were not detected using CMV PCR in plasma; whereas in times of white blood cell aplasia or blast crisis of leukemia, samples with active CMV infection in plasma could not be detected using blood cells. We conclude that CMV monitoring in whole blood could be favorable compared with assays using plasma or blood cells alone. Automated NA isolation could become an attractive tool for a more sensitive and better standardized molecular diagnostics.

Interstitial deletion of chromosome 3p: report of a patient and delineation of a proximal 3p deletion syndrome

We report on a patient with a de novo interstitial deletion of the proximal portion of the short arm of chromosome 3 (p12----14.2). The deleted portion excludes the constitutive fragile site assigned to band 3p14. The phenotype of the patient, together with that of three previously reported cases, seems to be sufficiently characteristic to allow the delineation of a proximal 3p deletion syndrome.

[Variations of intraocular pressure during valsalva's maneuver in relation to body position and length of the bulbus in myopia (author's transl)]

Intraocular pressure was measured in 49 persons of either sex while carrying out Valsalva's maneuver in erect and recumbent position. 16 of the tested persons had myopia up to -8.0 D. The average intraocular pressure in recumbent position was 2 mm Hg higher when compared to the erect position. During Valsalva's maneuver the intraocular pressure was elevated in erect as well as in recumbent position. Three characteristic patterns of variation of intraocular pressure were seen after cessation of Valsalva's maneuver. The intraocular pressure in myopic persons was slightly higher than in those with emmetropia.

[Preoperative prewarming as a routine measure. First experiences]

BACKGROUND

Despite the broad application of intraoperative warming new studies still show a high incidence of perioperative hypothermia. Therefore a prewarming program in the preoperative holding area was started.

METHODS

The efficacy of the prewarming program was assessed with an accompanying quality assurance check sheet over a period of 3 months.

RESULTS

During the 3 month test period 127 patients were included. The median length from arrival in the holding area to beginning prewarming was 6 min and the average duration of prewarming was 46±38 min. During prewarming the core temperature rose by 0.3±0.4°C to 37.1±0.5°C and decreased to 36.3±0.5°C after induction of anesthesia. At the end of the operation the core temperature was 36.4±0.5°C and 14% of the patients were hypothermic.

CONCLUSION

These data allow 2 conclusions: 1. Prewarming in the holding area is possible with a sufficient duration. 2. Prewarming is highly efficient even when performed over a relatively short duration.

Spherical arena reveals optokinetic response tuning to stimulus location, size, and frequency across entire visual field of larval zebrafish

Many animals have large visual fields, and sensory circuits may sample those regions of visual space most relevant to behaviours such as gaze stabilisation and hunting. Despite this, relatively small displays are often used in vision neuroscience. To sample stimulus locations across most of the visual field, we built a spherical stimulus arena with 14,848 independently controllable LEDs. We measured the optokinetic response gain of immobilised zebrafish larvae to stimuli of different steradian size and visual field locations. We find that the two eyes are less yoked than previously thought and that spatial frequency tuning is similar across visual field positions. However, zebrafish react most strongly to lateral, nearly equatorial stimuli, consistent with previously reported spatial densities of red, green, and blue photoreceptors. Upside-down experiments suggest further extra-retinal processing. Our results demonstrate that motion vision circuits in zebrafish are anisotropic, and preferentially monitor areas with putative behavioural relevance.

Hemodynamic effects of spontaneous breathing in the post-operative period

BACKGROUND

During mechanical ventilatory support, spontaneous breathing has been linked to improved hemodynamics. These findings may be explained by a decrease in intrathoracic pressure which may improve venous return to the heart. Such a mechanism should result in a dose-response relation between the amount of spontaneous breathing and an increase in the global end-diastolic volume (GEDV) and cardiac output (Q(t)).

METHODS

To test this hypothesis, 15 patients were studied after major elective surgery during weaning from mechanical ventilation using bilevel positive airway pressure (BIPAP). BIPAP allows unrestricted spontaneous breathing during every phase of the respiratory cycle. Thus, ventilatory support was modified by changing the mechanical respiratory rate only, whereas inspiratory airway pressure and PEEP were kept constant. GEDV and Q(t) were measured by transpulmonary thermodilution.

RESULTS

GEDV (P = 0.055), stroke volume (P = 0.027) and subsequently also Q(t) (P < 0.001) increased when spontaneous breathing increased. In contrast, no difference was observed for central venous pressure (P = 0.19).

CONCLUSION

The beneficial hemodynamic effects of spontaneous breathing during mechanical ventilatory support can partially be explained by improved venous return to the heart which increases stroke volume and Q(t).

Assessment of diaphragmatic function with cervical magnetic stimulation in critically ill patients

The objective of this study was to evaluate a non-volitional measurement to assess diaphragmatic function in intubated and mechanically ventilated patients in a prospective pilot interventional clinical trial. The study was conducted in an 18-bed postoperative intensive care unit based at a university hospital. Patients were prospectively assigned to two groups. Group 1 consisted of eight patients with ventilator weaning failure. Group 2 consisted of eight intubated and ventilated patients who were studied shortly after major surgery and were successfully extubated there-after The twitch pressure response after cervical magnetic stimulation of the phrenic nerves was measured at the endotracheal tube at different PEEP levels. In group 2 the twitch transdiaphragmatic pressure, defined as the difference between twitch gastric and twitch oesophageal pressure was also evaluated. In group 1 the mean twitch pressure at the endotracheal tube on PEEP 0, 5 and 10 cmH2O was 5.2, 4.5 and 2.6 cmH2O: In group 2 this was significantly higher (15.1 cmH2O on PEEP 0 and 12.2 cmH2O on PEEP 5). A good correlation was found between twitch diaphragmatic pressure and twitch pressure at the endotracheal tube (r2 = 0.96) and between twitch oesophageal pressure and twitch pressure at the endotracheal tube (r2 = 0.98). Patients with weaning failure have significantly lower twitch pressure at the endotracheal tube suggesting diaphragmatic dysfunction. Twitch pressure at the endotracheal tube may be a useful parameter to screen for diaphragmatic dysfunction in intubated critically ill patients. Further studies are needed to confirm these preliminary findings.

Quantification of haemagglutinin of influenza Tween-ether split vaccines by immunodiffusion

The haemagglutinin content of monovalent influenza whole virus and Tween-ether split vaccines derived therefrom, were assayed comparatively using single radial immunodiffusion (SRID, the only test recommended for influenza vaccines by the European Pharmacopoeia Commission), quantitative SDS-polyacrylamide gel electrophoresis and immunization of guinea pigs. If SRID was performed with split vaccines, reduced haemagglutinin values were consistently recorded which were 50-25% of values obtained before disruption of virions. If, however, disruption was conducted in the presence of excess detergent thus preventing aggregate formation of solubilized haemagglutinin, test values comparable to those of whole virus vaccines were obtained. In agreement with these results, immunization experiments revealed that whole virus and the corresponding split vaccines exhibited comparable immunogenicity in guinea pigs. From SDS-polyacrylamide gel electrophoresis and densitometer tracings obtained by scanning the gels after staining with either Coomassie Blue or fluorescein isothiocyanate-labelled concanavalin A it was calculated that about 90% of whole virus HA2 was recovered in Tween-ether split vaccines. From our experiments we conclude that precise quantification of solubilized haemagglutinin is not achievable by the single radial immunodiffusion test alone. Aggregate formation of solubilized haemagglutinin frequently occurs when the applied detergent is removed and, therefore, a physico-chemical method including an effective disaggregation procedure like SDS treatment in combination with PAGE is recommended.

Disynaptic specificity of serial information flow for conditioned fear

Memory encoding and retrieval rely on specific interactions across multiple brain areas. Although connections between individual brain areas have been extensively studied, the anatomical and functional specificity of neuronal circuit organization underlying information transfer across multiple brain areas remains unclear. Here, we combine transsynaptic viral tracing, optogenetic manipulations, and calcium dynamics recordings to dissect the multisynaptic functional connectivity of the amygdala. We identify a distinct basolateral amygdala (BLA) subpopulation that connects disynaptically to the periaqueductal gray (PAG) via the central amygdala (CeA). This disynaptic pathway serves as a core circuit element necessary for the learning and expression of conditioned fear and exhibits learning-related plasticity. Together, our findings demonstrate the utility of multisynaptic approaches for functional circuit analysis and indicate that disynaptic specificity may be a general feature of neuronal circuit organization.