Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease.

In 12 patients with chronic obstructive pulmonary disease (COPD) receiving pressure support ventilation (PSV), we studied the variability of respiratory muscle unloading and defined its physiologic determinants using a modified pressure-time product (PTP). Inspiratory PTP/min decreased as PSV was increased (p < 0.001), but there was considerable interindividual variation: coefficients of variations of up to 96%. On multiple linear regression analysis, 73 to 83% of the variability in inspiratory PTP was explained by inspiratory resistance, minute ventilation, and intrinsic positive end-expiratory pressure. Taking an inspiratory PTP/min of < 125 cm H2O.sec/min to represent a desirable level of inspiratory effort during PSV, a respiratory frequency of < or = 30 breaths/min was more accurate than a tidal volume > 0.6 L in predicting this threshold (p < 0.001). At PSV of 20 cm H2O, expiratory effort, quantitated by an expiratory PTP, was clearly evident in five patients before the cessation of inspiratory flow, signifying that the patient was "fighting" the ventilator; of note, these five patients had a frequency of < or = 30 breaths/min. In conclusion, patient-ventilator interactions in patients with COPD are complex, and events in expiration need to be considered in addition to those of inspiration.

Magnesium sulfate potentiates several cardiovascular and metabolic actions of terbutaline.

beta-Adrenergic agonists are useful for the emergency treatment of asthma. Recently, magnesium sulfate (MgSO4) has also been shown to be efficacious in this situation. beta-Agonists have unwanted cardiovascular and metabolic actions: increased systolic blood pressure, corrected QT interval (QTc), serum glucose and insulin, and decreased RR interval, diastolic blood pressure, serum potassium, phosphate, and calcium. As beta-agonists and MgSO4 quite possibly will be used in combination, we sought to determine how MgSO4 would affect these actions. Healthy young male adults were administered two doses of terbutaline sulfate, 0.25 mg subcutaneously, 30 min apart on two separate occasions, in a randomized, double-blind fashion. On one occasion, 4 g of MgSO4 was administered intravenously over the same 30-min period. On the other, normal saline solution was given as a placebo. Cardiovascular and metabolic variables were measured sequentially for 2 h. Data at 60 min with p values given for a summation of all time points are as follows: MgSO4 increased terbutaline's effects on the RR interval by 0.09 s, p < 0.0001; QTc interval by 0.01 s, p < 0.0007; diastolic blood pressure by 8 mm Hg, p = 0.0001; serum calcium by 0.13 mg/dl, p = 0.01; and glucose by 9 mg/dl, p < 0.0001. MgSO4 also mitigated the systolic blood pressure elevating the effect of terbutaline by 5 mm Hg (p = 0.007). The magnitude of the response potentiations was modest. We conclude that combining terbutaline and MgSO4 is unlikely to result in serious short-term adverse events, if used acutely in patients with relatively normal cardiac and metabolic function. MgSO4 may act by potentiating the effect of beta-agonists on magnesium requiring enzymes such as adenyl cyclase.

Pressure support. Changes in ventilatory pattern and components of the work of breathing.

To evaluate the interaction between patient and ventilator during widely varying levels of pressure support (PS) ventilation, we studied 33 patients who had undergone aortocoronary bypass. All patients were without preoperative evidence of lung disease and had left ventricular ejection fractions greater than 45 percent. We assessed both changes in ventilatory pattern and the use of an extension of the Campbell technique to determine the components of the mechanical work of breathing (WOB). Patients were placed on 0, 10, 20, and 30 cm H2O of PS. We found that increasing the pressure support level (PSL) did not change minute ventilation, PCO2, or pH despite large changes in both rate and depth of breathing. The inspiratory time fraction was consistently and progressively reduced as PS increased. Although mean inspiratory flow (MIF) increased by 75 +/- 9 (SE) percent as the PSL increased to 30 cm H2O, mean airway pressure rose only 3.5 +/- 0.1 cm H2O. Observed changes in the resistive and elastic components of WOB at PSL greater than 0 were consistent with values predicted from baseline observations and changes in VT and MIF demonstrating that the Campbell technique of separating resistive and elastic components of the patient's WOB during unassisted ventilation can be extended to the analysis of WOB during mechanical ventilation. We were surprised to observe that although inspiratory WOB fell 67 +/- 13 percent as the PSL increased to 30 cm H2O, postinspiratory work by the inspiratory muscles (WOBPIIM) did not show significant change. The persistence and substantial values of WOBPIIM in some patients suggested the presence of significant patient-ventilator dyssynchrony, especially at higher levels of PS. Total inspiratory WOB per minute, including both patient WOB and WOB by the ventilator, increased by 186 +/- 29 percent, demonstrating that PS results in a respiratory pattern requiring substantially greater total mechanical work.

Thoracic traction on the trachea: mechanisms and magnitude.

Both inspiratory increases and tonic thoracic traction (pull of the thorax) on the trachea [Ttx(tr)] have been shown to improve patency of the upper airway. To evaluate the origins and magnitude of Ttx(tr), we studied 15 anesthetized tracheotomized dogs. We divided the midcervical trachea and attached the thoracic stub to a strain gauge. Ttx(tr), esophageal pressure, and carinal displacement were observed during various conditions. These included unobstructed and obstructed spontaneous breathing, mechanical ventilation at various levels of positive end-expiratory pressure, and progressive hypercapnic stimulation. Observations during spontaneous breathing were performed before and after vagotomy. We found that inspiratory increases in Ttx(tr) were substantial, averaging 81 +/- 8 g force and increasing to 174 +/- 22 g force at an end-expiratory CO2 concentration of 10%. Ttx(tr) did not result simply from the pull of mediastinal and pulmonary structures transmitted through the carina. Changes in intrathoracic pressure acted independently to either draw the trachea into or push the trachea out of the thorax. Thus Ttx(tr) could be explained as the sum of mediastinal traction and force generated by changes in intrathoracic pressure.

Thoracic influence on upper airway patency.

Patency of the upper airway (UA) is usually considered to be maintained by the activity of muscles in the head and neck. These include cervical muscles that provide caudal traction on the UA. The thorax also applies caudal traction to the UA. To observe whether this thoracic traction can also improve UA patency, we measured resistance of the UA (RUA) during breathing in the presence and absence of UA muscle activity. Fifteen anesthetized dogs breathed through tracheostomy tubes. RUA was calculated from the pressure drop of a constant flow through the isolated UA. RUA decreased 31 +/- 5% (SEM) during inspiration. After hyperventilating seven of these dogs to apnea, we maximally stimulated the phrenic nerves to produce paced diaphragmatic breathing. Despite absence of UA muscle activity, RUA fell 51 +/- 11% during inspiration. Graded changes were produced by reduced stimulation. In six other dogs we denervated all UA muscles. RUA still fell 25 +/- 7% with inspiration in these spontaneously breathing animals. When all caudal ventrolateral cervical structures mechanically linking the thorax to the UA were severed, RUA increased and respiratory fluctuations ceased. These findings indicate that tonic and phasic forces generated by the thorax can improve UA patency. Inspiratory increases in UA patency cannot be attributed solely to activity of UA muscles.

Action of nicotine on the respiratory activity of the diaphragm and genioglossus muscles and the nerves that innervate them.

Nicotine is known to alter respiration by stimulating peripheral chemoreceptors and receptors within the brain. In this study the sites of action and the effects of nicotine on hypoglossal nerve activity were compared to its effects on phrenic activity in paralyzed, vagotomized and chloralose-anesthetized cats. Since anesthesia is known to affect respiratory responses, we also compared the effects of intravenous nicotine given to conscious unsedated cats on genioglossus and diaphragm electrical activity. In eight conscious animals intravenous doses of nicotine ranging between 10 ng and 200 micrograms increased genioglossus activity significantly more than diaphragm activity. Studies in 26 anesthetized animals included injection of nicotine, intravenously, in the lateral ventricles, and application of nicotine to the ventrolateral surface of the medulla (the putative site of the central chemoreceptors) before and after section of the carotid sinus nerves. With all these interventions, changes in hypoglossal nerve activity were significantly greater than changes in phrenic nerve activity. The responses to nicotine could be blocked by application of hexamethonium to the ventrolateral medullary surface or by cooling the same area. The results indicate that: nicotine increases hypoglossal nerve activity by both its peripheral and central effects; nicotine has differential effects on different respiratory muscles and nerves; and the central action of nicotine may be mediated largely through receptors located near the ventral medullary surface.

Respiratory function of hyoid muscles and hyoid arch.

The position of the hyoid arch suggests that it supports soft tissue surrounding the upper airway (UA) and can act to maintain UA patency. We also suspected that muscles inserting on the hyoid arch might show respiratory patterns of activity that could be affected by respiratory stimuli. To test these possibilities, we moved the hyoid arch ventrally in six anesthetized dogs either by traction on it or by stimulation of hyoid muscles. UA resistance was decreased 73 +/- (SE) 6% and 72 +/- 6% by traction and stimulation during expiration and 57 +/- 15% and 52 +/- 8% during inspiration. Moving averages of the geniohyoid (GH) and thyrohyoid (TH) obtained in six other dogs breathing 100% O2 showed phasic respiratory activity while the sternohyoid (SH) showed phasic respiratory activity in only two of these animals and no activity in four. With progressive hypercapnia, GH and TH increased as did SH when activity was already present. Airway occlusion at end expiration augmented and prolonged inspiratory activity in the hyoid muscles but did not elicit SH activity if not already present. Occlusion at end inspiration suppressed phasic activity in hyoid muscles for as long as in the diaphragm. After vagotomy activity increased and became almost exclusively inspiratory. Activity appeared in SH when not previously present. Duration and amplitude of hyoid muscle activity were increased with negative UA pressure and augmented breaths. We conclude that the hyoid arch and muscles can strongly affect UA flow resistance. Hyoid muscles show responses to chemical, vagal, and negative pressure stimuli similar to other UA muscles.

Phasic volume-related feedback on upper airway muscle activity.

The effects of vagally mediated volume-related feedback on the activity of upper airway muscles was assessed in nine pentobarbital-anesthetized, tracheostomized, spontaneously breathing dogs. Moving average electrical activity was recorded before and during single-breath airway occlusions from the genioglossus, posterior cricoarytenoid, and alae nasi muscles and compared with simultaneously recorded tidal volume and electrical activity of the phrenic nerve (6 dogs) or diaphragm (3 dogs). The normally early peak of upper airway muscle activity during unoccluded breaths was delayed to late or end inspiration during occluded breaths. Inspiratory depression started at a lower volume above end-expiratory volume and at an earlier time after inspiratory onset for the upper airway muscles than for the phrenic nerve and the diaphragm. The amount of depression at the end of inspiratory airflow was larger for all of the upper airway muscles than for the phrenic nerve and diaphragm. Depressive effects were most prominent in the genioglossus, followed by the posterior cricoarytenoid and the alae nasi. After vagotomy, depressive effects of volume-related feedback were no longer seen. These results suggest that activity of the upper airway muscles is modulated by vagally mediated feedback, apparently to a larger extent than that of the diaphragm and phrenic nerve.

Nasal and laryngeal reflex responses to negative upper airway pressure.

The effects of negative pressure applied to just the upper airway on nasal and laryngeal muscle activity were studied in 14 spontaneously breathing anesthetized dogs. Moving average electromyograms were recorded from the alae nasi (AN) and posterior cricoarytenoid (PCA) muscles and compared with those of the genioglossus (GG) and diaphragm. The duration of inspiration and the length of inspiratory activity of all upper airway muscles was increased in a graded manner proportional to the amount of negative pressure applied. Phasic activation of upper airway muscles preceded inspiratory activity of the diaphragm under control conditions; upper airway negative pressure increased this amount of preactivation. Peak diaphragm activity was unchanged with negative pressure, although the rate of rise of muscle activity decreased. The average increases in peak upper airway muscle activity in response to all levels of negative pressure were 18 +/- 4% for the AN, 27 +/- 7% for the PCA, and 122 +/- 31% for the GG (P less than 0.001). Rates of rise of AN and PCA electrical activity increased at higher levels of negative pressure. Nasal negative pressure affected the AN more than the PCA, while laryngeal negative pressure had the opposite effect. The effects of nasal negative pressure could be abolished by topical anesthesia of the nasal passages, while the effects of laryngeal negative pressure could be abolished by either topical anesthesia of the larynx or section of the superior laryngeal nerve. Electrical stimulation of the superior laryngeal nerve caused depression of AN and PCA activity, and hence does not reproduce the effects of negative pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoconstriction: upper airway dilating muscle and diaphragm activity.

The effect of bronchoconstriction on the activity of the diaphragm and the upper dilating airway muscles were studied by administering graded doses of methacholine to anesthetized dogs spontaneously breathing oxygen. The electrical activity of the genioglossus, posterior cricoarytenoid, and alae nasi was compared with that of the diaphragm at different levels of pulmonary resistance. Induced bronchoconstriction was associated with increases in the electrical activity of all muscles examined. Bilateral cervical vagotomy diminished but did not prevent the bronchoconstrictor effects of methacholine. When greater concentrations of methacholine were administered to produce bronchoconstriction comparable with that produced prevagotomy, both genioglossus and diaphragm activity increased. This study indicates that the upper airway muscles and the diaphragm respond to bronchoconstriction. The activation of the upper airway muscles with bronchoconstriction may decrease upper airway resistance serving to partially offset increases in pulmonary resistance and to modulate airflow patterns during bronchoconstriction.

Activity of upper airway muscles during augmented breaths.

The effect of augmented breaths on the electrical activity of upper airway (UAW) muscles was studied in fourteen spontaneously breathing anesthetized dogs. Moving average traces of the electrical activity recorded from the genioglossus (GG), the posterior cricoarytenoid (PCA), and the alar portion of the nasalis muscle (AN) were compared to tracings of diaphragm electrical activity. During augmented breaths the electrical activity of the diaphragm showed the characteristic biphasic pattern previously described: an initial phase following the contour of a normal breath (phase I) and an augmented phase arising near the crest of the initial phase (phase II). During all augmented breaths, the GG, PCA and AN showed the same biphasic pattern as the diaphragm. The normally rounded shape of UAW muscle EMG activity during control breaths changed to a more sharply peaked form during the second phase of the augmented breath. Onset of activity of all UAW muscles studied preceded that of the diaphragm; during control breaths, the average interval was 0.29 sec for the PCA, 0.25 sec for the GG and 0.14 sec for the AN (P less than 0.05). The amount of pre-activation was decreased to less than 0.10 sec during the second phase of the augmented breath. The slopes and amplitudes of phase I were similar to that of control breaths. The peak EMG activity of the augmented breath was 214% of the control breaths for the diaphragm, 247% for the GG, 168% for the AN and 161% for the PCA (P less than 0.005 for GG, P less than 0.001 for the others). During hyperoxic hypercapnia the slopes and amplitudes of phase II remained nearly constant for all four muscles, whereas the slopes and amplitudes of phase I changed with the chemical drive just as in control breaths. UAW resistance, recorded in five additional spontaneously breathing anesthetized dogs, was 32% less during inspiration than expiration during control breaths, and 31% less during phase I of augmented breaths; there was a further 18% decrease during phase II of augmented breaths (P less than 0.001). The results suggest that mechanisms responsible for augmented breaths act similarly on upper airway muscles and the diaphragm.

Adsorbent and cathartic inhibition of enteral drug absorption.

The effects on absorption of drugs given by mouth of adsorbents (charcoals and resins) and cathartics (osmotic and oil) were studied in vitro and in vivo using acetaminophen (paracetamol) as a test drug. In vitro adsorption isotherms were measured at 37 degrees C in simulated gastric and gastric plus intestinal juices. Maximum binding capacity (MBC) of 16 charcoals and resins varied 30-fold, from 0.36 to 9.32 mol/kg. Dissociation constants varied directly with MBC. In vitro adsorption was little changed by addition of d-mannitol and d-sorbitol, N-acetylcysteine (NAC) or l-methionine. Acetaminophen (0.6 g/kg by orogastric tube) was given to 17 dogs protected by i.v. injections of NAC and methylene blue. One minute later, dogs were given: 1) water; 2) Norit A or Nuchar 1110 charcoal, 3 g/kg; 3) d-mannitol and d-sorbitol, 2 g/kg or castor oil, 3 ml/kg; or 4) both charcoal and either d-mannitol and d-sorbitol or castor oil. Cathartics alone decreased the area under plasma acetaminophen concentrations 15 to 30%. Charcoals alone reduced the area under plasma acetaminophen concentration 93%. Each cathartic diminished the charcoal inhibition of acetaminophen absorption. In mice given acetaminophen by orgastric tube, the acute lethality was decreased more by a new petroleum-based charcoal than by standard wood-based charcoals. Reduction of acetaminophen lethality in mice paralleled the in vitro MBC of adsorbents. Charcoals did not avidly adsorb l-methionine or NAC in vitro. Charcoal did not decrease the l-methionine or NAC protection of acetaminophen-poisoned mice. Charcoals with large MBC diminish absorption and lethality of acetaminophen taken by mouth; cathartics have little effect on acetaminophen absorption.