Ventilation-perfusion lines and gas exchange in liquid breathing: theory.

Alveolar exchange of a gas is governed by the ventilation-perfusion ratio (VA/Q) and the Ostwald partition coefficient for that species. We altered the Ostwald coefficients for O2 and CO2 by considering an animal breathing water or a fluorocarbon (FC-80) and studied the effects on gas exchange. Among our conclusions are the following. 1) When the ratio of the CO2 to O2 solubility in the inspirate exceeds the ratio of the O2 to the CO2 slope of the blood dissociation curve, as in water breathing, the VA/Q line becomes concave upward, and elements having a low VA/Q differ from each other more in terms of CO2 than of O2. 2) As the ratio of the CO2 to O2 solubility in the inspired medium increases, CO2 elimination becomes more dependent on perfusion. 3) At times, the same R will prevail in areas having different VA/Q values. 4) The alveolar-to-arterial O2 and CO2 differences resulting from a given VA/Q distribution do not depend on the O2 and CO2 solubility coefficients of the inspired medium, but on the inspired and mixed venous concentrations necessary to maintain adequate arterial gas levels in the presence of different inspired media.

Cardiopulmonary readjustments in passive tilt.

There is ample evidence that posture affects many cardiorespiratory variables, but the extent to which secondary reflex mechanisms complement or oppose the primary gravity effect is not clear. We have addressed ourselves to this problem by studying five normal volunteers, passively tilted from the supine to the upright position in 15 degrees increments, in random sequence, determinging cardiac output (Q), heart rate (HR), stroke volume (SV), minute and alveolar ventilation (VE and VA), functional residual capacity (FRC), and arterial-end-tidal PCO2 pressure difference. In each position, four to five measurements were obtained by noninvasive techniques. Changes in Q and in FRC were linearly related to the sine of the tilt angle, indicating that reflexes were either absent or that their net effect was proportional to the effects of gravity; this was clearly not the case for other variables (HR, SV, VE, VA) in which it was possible to demonstrate threshold values for the appearance of secondary changes.

Central hypoventilation syndrome: experience with bilateral phrenic nerve pacing in 3 neonates.

Successful long-term phrenic nerve pacing has been reported in adults with acquired central hypoventilation syndrome. This report summarizes our experience with phrenic nerve pacing in 3 infants with congenital central hypoventilation syndrome. The electrodes were implanted in the lower thoracic portion of each phrenic nerve. In all patients. bilateral simultaneous pacing was required to maintain an adequate arterial PO2, tidal volume, and minute ventilation during quiet sleep. Case 1 died of problems primarily related to the severe cor pulmonale that had been present before pacemaker insertion; at autopsy, the pacemaker system was intact and there were no significant phrenic nerve abnormalities. Case 2 later developed failure of awake ventilatory control and died because of extensive phrenic nerve damage incurred by 19 days of continuous pacing. Case 3 has received quiet sleep pacemaker support since September 1977 and has been able to maintain normal quiet sleep ventilation in this manner. Phrenic nerve pacing can be successful in infants as long as continuous pacing is not required. Bilateral simultaneous pacing appears to be an appropriate alternative to home-based intermittent positive-pressure breathing for long-term management of children with central hypoventilation syndrome.

The effects of changes of maternal PaO2 and PaCO2 on the fetal PaO2 and PaCO2--in vivo study.

Umbilical PaO2 and PaCO2 were continuously monitored in vivo in acute fetal lamb preparations with a semipermeable membrane connected to a mass spectrometer. The response time of this system (0 to 90% of final value) was 36 sec. In seven pregnant sheep (128--135 days gestation) the maternal inspired mixture was abruptly changed and the following changes in fetal PaO2 and PaCO2 were observed: (1) 100% O2 to room air: PaO2 decreased from 21.5 +/- 0.8 (mean +/- SEM) to 14 +/- 1.1 mm Hg at a rate of 1.63 +/- 0.33 mm Hg/min. Following return to 100% O2 the PaO2 returned to 21 +/- 1.1 mm Hg at a rate of 2.44 +/- 0.4 mm Hg/min. (2) 100% O2 to 12% O2/10% CO2: after 6 min the PaO2 fell from 19.3 +/- 1.3 to 6.3 +/- 0.3 mm Hg at a rate of 4.65 mm Hg/min and the PaCO2 rose from 37 +/- 8 to 70 +/-5 mm Hg. At 100% O2 the PaO2 returned to 19 +/- 1.0 mm Hg at a rate of 11.76 +/- 0.086 mm Hg, the PaCO2 to 39 +/- 7 mm Hg. (3) 100% O2 to 90% O2/10% CO2. The PaO2 and PaCO2 increased by 4.7 and 22 mm Hg, respectively. The changes of fetal PaO2 and PaCO2 occurred after 1 minute of changing in maternal inspired mixture except in the transition from 12% O2/10% CO2 to 100% O2 (34 +/- 12 sec). Following the reinstitution of 100% the fetal PaO2 and PaCO2 returned to their previous values within 4 and 16 min, respectively.

The effect of independent variations in inspiratory-expiratory ratio and end expiratory pressure during mechanical ventilation in hyaline membrane disease: the significance of mean airway pressure.

The specific aspects of the respiratory cycle during mechanical ventilation that allow for optimum gas exchange are still controversial. To further clarify the relationship of inspiratory:expiratory ratio and positive end expiratory pressure to optimum ventilation and oxygenation, five premature lambs with severe hyaline membrane disease were ventilated with volume-present infant ventilators at I:E ratios of 1:4 and 1:1 and PEEP levels of 0, 5, and 10 cm H2O. For each I:E ratio/PEEP combination, pH, Pao2, PaCO2, PAO2, PACO2, peak inspiratory pressure, mean inspiratory pressure, and mean airway pressure were measured and compared. Optimum ventilation and oxygenation were related to MAP, but not to I:E ratio, PIP, or MIP. As MAP increased from 6 to 14 cm H2O, progressive improvement in Pao2, PaCO2 (A-a) DO2 and (a-A) DCO2 was evident. Above 14 cm H2O, there was progressive deterioration in these measurements. There was also a direct relationship between MAP and mean pleural pressure. These results indicate that during mechanical ventilation there is an optimum MAP at which gas exchange is best. Since MAP changes with any change in PIP, PEEP, or I:E ratio, it provides a useful composite measure of all pressures transmitted to the airways by the ventilator.

An in vivo mass spectrometer system for the continuous monitoring of Po2 and Pco2.

A mass spectrometer blood gas catheter system for the continuous in vivo analysis of Po2 and Pco2 has been presented. This system has been experimentally evaluated and demonstrated to be reliable and reproducible over a period of 30 hr following insertion of the catheter in the abdominal aorta. Although the present catheter design does not allow insertion through an existing umbilical arterial line in neonates, a clinical evaluation will be undertaken when a more flexible catheter becomes available.