Assessment of Upper Airways Obstruction

An indication of obstruction to the upper airways (trachea and larynx) may be obtained by calculating the ratio of the forced expired volume in one second to the peak expiratory flow rate (FEV₁/PEFR). This index was found to be usually less than 10 in normal subjects (mean 7·3), and in patients with asthma (mean 6·9), chronic bronchitis (mean 7·7), or interstitial lung disease (mean 6·3). A study of simulated upper airways obstruction showed that this index rises as the obstruction becomes more severe. All of 18 patients with proved upper airways obstruction had FEV₁/PEFR indices greater than 10 (mean 14·0). This test can be carried out with forced expiratory manoeuvres only, and it does not require the use of complicated equipment. An FEV₁/PEFR ratio greater than 10, when upper airways obstruction is suspected, indicates that significant obstruction may be present. High values suggest that the obstruction may be severe, and that further investigations are indicated.     

Inspiratory Obstruction

Obstructing lesions of the trachea and larynx which cause a predominantly inspiratory obstruction can be satisfactorily diagnosed by measuring both F.I.V.₁ and F.E.V.₁. Chronic airways obstruction involving intrathoracic airways produces a much lower F.E.V.₁/F.I.V.₁ percentage than normal, whereas obstruction to larynx and trachea causes a raised F.E.V.₁/F.I.V.₁ percentage. If flow-volume measurements are not available the F.E.V.₁/F.I.V.₁ percentage should provide a simple and useful method for diagnosis of upper airways obstruction.In one of the patients reported a predominantly inspiratory obstruction caused CO₂ retention. In patients with airways obstruction the correlation between Pco₂ and F.I.V.₁ was found to be the same as between Pco₂ and F.E.V.₁. This suggests that respiratory failure can be caused by either inspiratory or expiratory airways obstruction and that neither is of greater importance in producing CO₂ retention.     

Effects of Salbutamol and Isoprenaline Phenylephrine in Reversible Airways Obstruction

Ventolin (salbutamol) and Medihaler-Duo (isoprenaline/phenylephrine combination) standard pressurized inhalers were used to administer doses of two or six “puffs” to 16 patients with known reversible airways obstruction. The doses were administered in random order over two days. Both the Ventolin and Medihaler-Duo inhalers substantially increased FEV₁, but in the doses used salbutamol was more effective than isoprenaline/phenylephrine (P < 0·01). There was no significant difference between two and six puffs of salbutamol, though there seemed to be an advantage of six puffs of isoprenaline/phenylephrine over two puffs (P < 0·05). Adrenaline (1/1,000) 0·5 ml and atropine 0·6 mg produced similar increases in FEV₁ to those produced by salbutamol.The Pao₂ fell more than 5 mm Hg in three patients after salbutamol and in three after isoprenaline/phenylephrine. There was no significant fall in mean Pao₂ in any of the treatment groups. It is concluded that the Ventolin inhalant, administered in the conventional dose of two puffs, is as effective a bronchodilator as subcutaneous adrenaline and atropine, is more effective than the Medihaler-Duo, and is without detectable side effects.     

Airways resistance and specific conductance for the diagnosis of obstructive airways diseases

Background

Airway resistance (R_AW) and specific airway conductance (sG_AW) are measures that reflect the patency of airways. Little is known of the variability of these measures between different lung diseases. This study investigated the contribution of R_AW and sG_AW to a diagnosis of obstructive airways disease and their role in differentiating asthma from COPD.

Methods

976 subjects admitted for the first time to a pulmonary practice in Belgium were included. Clinical diagnoses were based on complete pulmonary function tests and supported by investigations of physicians’ discretion. 651 subjects had a final diagnosis of obstructive diseases, 168 had another respiratory disease and 157 subjects had no respiratory disease (healthy controls).

Results

R_AW and sG_AW were significantly different (p < 0.0001) between obstructive and other groups. Abnormal R_AW and sG_AW were found in 39 % and 18 % of the population, respectively, in which 81 % and 90 % had diagnosed airway obstruction. Multiple regression revealed sG_AW to be a significant and independent predictor of an obstructive disorder. To differentiate asthma from COPD, R_AW was found to be more relevant and statistically significant. In asthma patients with normal FEV₁/FVC ratio, both R_AW and sG_AW were more specific than sensitive diagnostic tests in differentiating asthma from healthy subjects.

Conclusions

R_AW and sG_AW are significant factors that contribute to the diagnosis and differentiation of obstructive airways diseases.     

Value of measuring end tidal partial pressure of carbon dioxide as an adjunct to treadmill exercise testing

The end tidal partial pressure of carbon dioxide (Pco₂) was measured during treadmill exercise in 30 normal controls and 113 patients referred for assessment of chest pain. Among the 92 patients without significant ST depression hypocapnia occurred more often in those reporting “typical” than “atypical” chest pain (17 of 22 patients compared with 29 of 70; p<0·01). Hypocapnia was uncommon in patients with significant ST depression whether reporting typical or atypical chest pain (one of 10 patients and two of 11, respectively).Hypocapnia at rest (Pco₂ <4 kPa) occurred in 16 (14%) patients but in only one control. Hypocapnia occurred during or after exercise in only one control and three of the 21 patients with significant ST depression on exercise (group 1). The remaining 92 patients were divided into those with a history suggestive of hyperventilation (group 2; n=30) and those without (group 3; n=62). Hypocapnia developed significantly more often in both these groups (21 and 25 patients respectively) than in controls or patients with significant ST depression.An abnormal response of the Pco₂ to exercise provided objective data to support a clinical suspicion of chest pain induced by hyperventilation in 24 cases, suggested a cause for equivocal ST depression other than coronary stenosis in five patients, and led to the diagnosis of previously unsuspected respiratory disease in 14 patients.Measurement of end tidal Pco₂ gives additional valuable diagnostic information during the conventional treadmill exercise test in patients with both typical and atypical chest pain.     

A comparison of descending aortic and “arterialized” capillary blood in the sick newborn

Comparison was made of 53 “arterialized” capillary (heel prick) samples with descending aortic blood in 26 babies, of whom 24 were less than one week old and 18 had R.D.S.“Arterialized” capillary blood is an accurate and practical means of assessing aortic blood pH and Pco₂ over a range of 6.69 to 7.54 and 18 to 94 mm. Hg respectively.“Arterialized” capillary sampling is a reliable means of assessing descending aortic Po₂ when the “arterialized” capillary value is less than 60 mm. Hg.When higher than 60 mm. Hg the “arterialized” capillary oxygen tension may be considerably less than that of the blood in the descending aorta, hence the “arterialized” capillary blood oxygen tension method is unreliable in estimating systemic oxygenation when the descending aortic oxygen tension is more than 60 mm. Hg.     

Recurrent ventricular fibrillation treated by multiple countershocks.

Dichlorphenamide was administered to 13 patients with chronic respiratory failure, and the effects on gas exchange at rest and during exercise and on the acid-base state of CSF were observed. The ventilation for a given level of CO₂ production was increased both at rest and during exercise, resulting in an increased arterial Po₂ and decreased Pco₂.The ventilatory stimulation paralleled the development of a metabolic acidosis but was not associated with tissue CO₂ accumulation. Indeed, CSF Pco₂ and the oxygenated mixed venous (rebreathing) Pco₂ fell by the same amount as arterial Pco₂. The level of CO₂ elimination after two minutes of exercise was as great for a given work load after dichlorphenamide as before. These findings do not support the view that the drug impairs CO₂ transport from tissues either at rest or during exercise. They are most consistent with the view that the primary locus of action of dichlorphenamide in therapeutic doses is the kidney. The metabolic acidosis which results is likely the basis of the respiratory stimulatin, perhaps by its effects on the CSF H₂CO₃-HCO₃ - system. Inhibition of carbonic anhydrase in the red cell and choroid plexus are probably unimportant effects.     

Non-invasive tracking of peripheral ventilatory response to carbon dioxide

We propose a new method for quantifying the ventilatory sensitivity of the peripheral chemoreceptors to changes in CO₂ through analysis of the natural breath-to-breath variations in ventilation (y) and alveolar Pco₂ (x). This technique is truly non-invasive in that the need for administering CO₂-enriched mixtures is circumvented, and peripheral chemosensitivity is assessed while the respiratory control system operates in its normal eucapnic state, unperturbed by external interventions. The method is based on solution of the inverse problem relating the cross-correlation between alveolar Pco₂ and ventilation changes, and the autocorrelation of changes in alveolar Pco₂. Tests are performed using simulated data generated by a closed-loop respiratory control model. The impulse response of the controller and the convective delay between lungs and chemoreceptors are estimated from the data. Subsequently, the best exponential fit to the estimated impulse response yields values for the effective controller gain (G) and the associated time constant of the response. The estimates of G contain a small contribution from the control chemoreflex gain; however, the relation between changes in G and changes in peripheral gain remains unaltered. The effects of other details in the computation procedure, such as length of data sequence, maximum number of correlation lags and starting lag number, are also investigated.     

Effect of Mechanical Loading on Ventilatory Response to CO2 and CO2 Excretion

The ventilatory response to CO₂ (S) and respiratory exchange ratio have been measured in 10 healthy subjects breathing naturally and through added resistive loads. The changes in these values produced by the added loads were shown to be correlated with the unloaded CO₂ responsiveness. The results indicated that poorly responsive individuals had a greater depression of ventilatory response to CO₂ and were more liable to retain CO₂.These observations raise the possibility that the constitutional CO₂ responsiveness of an individual influences the alveolar ventilation achieved in the presence of airways obstruction. The propensity to develop respiratory failure may thus be conditioned by the premorbid CO₂ responsiveness.     

Feasibility and Safety of Fiber Optic Micro-Imaging in Canine Peripheral Airways

Purpose

To assess the feasibility and safety of imaging canine peripheral airways (<1 mm) with an experimental micro-imaging fiber optic bronchoscope.

Methods

Twenty healthy dogs were scoped with a micro-imaging fiber optic bronchoscope (0.8 mm outer diameter). Images at various levels of the bronchioles, mucosal color, and tracheal secretions were recorded. The apparatus was stopped once it was difficult to insert. CT imaging was performed simultaneously to monitor progression. The safety of the device was evaluated by monitoring heart rate (HR), respiratory rate (RR), mean artery pressure (MAP), peripheral oxygen saturation (SpO₂) and arterial blood gases (partial pressure of arterial carbon-dioxide, PaCO₂, partial pressure of arterial oxygen, PaO₂, and blood pH).

Results

(1) According to the CT scan, the micro-imaging fiber was able to access the peripheral airways (<1 mm) in canines. (2) There was no significant change in the values of HR, MAP, pH and PaCO₂ during the procedure (P>0.05). Comparing pre-manipulation and post-manipulation values, SpO₂ (F = 13.06, P<0.05) and PaO₂ (F = 3.01, P = 0.01) were decreased, whereas RR (F = 3.85, P<0.05) was elevated during the manipulation. (3) Self-limited bleeding was observed in one dog; severe bleeding or other complications did not occur.

Conclusion

Although the new apparatus had little effect on SpO₂, PaO₂ and RR, it can probe into small peripheral airways (<1 mm), which may provide a new platform for the early diagnosis of bronchiolar diseases.     

Impaired Water Handling in Chronic Airways Disease

The response to a standard water load (20 ml/kg body weight) was studied in 20 patients with chronic obstructive airways disease and in 13 healthy subjects. The percentage of the water load excreted in four hours was significantly lower in the patients (mean 51%) than in the controls (mean 106%). The maximum urine flow, osmolar clearance, free water clearance, and creatinine clearance were also significantly reduced in the patients. There was a significant inverse correlation between the percentage of load passed and the arterial PCO₂ (r = -0·798). Among the several possible causes of the reduced excretion of water which are discussed is a direct effect of hypercapnia.     

Effects of nitrite-induced methaemoglobinaemia on oxygen affinity of carp blood

Synopsis The oxygen transport characteristics and the acid-base status of carp blood was studied in vitro by equilibration of blood samples with and without addition of 5mmol l^–1 of nitrite for 30 min at various Po₂ values in combination with Pco₂ of 1.5 and 5.7mmHg (0.2 and 0.76kPa). After equilibration pH, Po₂, Pco₂, and Co₂ as well as methaemoglobin and HCO₃ ^– concentration were determined and oxygen dissociation curves established. At Pco₂ of 1.5mmHg (0.2kPa) oxygen affinity, expressed by a normal P₅₀ of 3.3mmHg (0.44kPa) was unaffected by nitrite exposure, whereas at Pco₂ 5.7 (0.76kPa), nitrite exposure shifted P₅₀ from 7.59mmHg (1.01kPa) to 21.9mmHg (2.92kPa). Methaemoglobin formation was greater at the higher Pco₂ and increased with falling Po₂. Erythrocyte shrinkage and rising plasma [HC0₃ ^–] during nitrite exposure indicated that the erythrocyte osmoregulation was significantly affected. The present results indicate significantly reduced oxygen affinity upon exposure of carp blood to nitrite. This result contrasts with findings in mammalian blood, where oxygen affinity is greatly enhanced.     

The Rate of Photorespiration during Photosynthesis and the Relationship of the Substrate of Light Respiration to the Products of Photosynthesis in Sunflower Leaves

Single attached leaves of sunflower (Helianthus annus L. “Mennonite”) were supplied ¹⁴CO₂ of constant specific radioactivity in gas mixtures containing various CO₂ and O₂ concentrations. The ¹⁴CO₂ and CO₂ fluxes were measured concurrently in an open system using an ionization chamber and infrared gas analyzer.     

Utilization of Exogenous Inorganic Carbon Species in Photosynthesis by Chlorella pyrenoidosa

The nature of the inorganic carbon utilized during photosynthesis by Chlorella pyrenoidosa was investigated using three experimental techniques (open gas analysis system with “artificial leaf” or “aqueous” chambers and O₂ electrode system) to measure carbon assimilation. Photosynthesis was studied as a function of pH and CO₂ concentration. The CO₂ concentration was inadequate to meet the requirements of photosynthesis only when HCO₃⁻ was added at high pH. Under all other conditions, the low and constant K_m (CO₂), in contrast to the highly variable K_m (HCO₃⁻), suggested that CO₂ was the major species utilized.     

Role of Carbon Dioxide in Catabolism of Propane by “Nocardia paraffinicum” (Rhodococcus rhodochrous)

The catabolism of propane by “Nocardia paraffinicum” (Rhodococcus rhodochrous) has been shown to involve CO₂ fixation after its oxidation to propionic acid. “N. paraffinicum” failed to grow on either propane or 1-propanol in the absence of CO₂. The rate of propane utilization was directly related to the initial CO₂ concentration, and Warburg respirometry suggested that CO₂ was required for the catabolism of 1-propanol, propionaldehyde, and propionate but not for 2-propanol. These data also suggested that the predominant pathway for the utilization of propane by “N. paraffinicum” was through 1-propanol. The use of [2-¹⁴C]propane and ¹⁴CO₂ confirmed the catabolism of propane and the fixation of CO₂. Through the use of these isotopes and the pyruvate carboxylase inhibitor sodium arsenite, the labeled 2,4-dinitrophenylhydrazine derivative of pyruvate was trapped and isolated via thin-layer chromatography. The trapping of [¹⁴C]pyruvate in this manner was considered to be indicative of the presence of the methylmalonyl coenzyme A pathway for CO₂ fixation.     

Correlation of Stomatal Conductance with Photosynthetic Capacity of Cotton Only in a CO2-Enriched Atmosphere: Mediation by Abscisic Acid?

Some evidence indicates that photosynthetic rate (A) and stomatal conductance (g) of leaves are correlated across diverse environments. The correlation between A and g has led to the postulation of a “messenger” from the mesophyll that directs stomatal behavior. Because A is a function of intercellular CO₂ concentration (c_i), which is in turn a function of g, such a correlation may be partially mediated by c_i if g is to some degree an independent variable. Among individual sunlit leaves in a cotton (Gossypium hirsutum L.) canopy in the field, A was significantly correlated with g (r² = 0.41, n = 63). The relative photosynthetic capacity of each leaf was calculated as a measure of mesophyll properties independent of c_i. This approach revealed that, in the absence of c_i effects, mesophyll photosynthetic capacity was unrelated to g (r² = 0.06). When plants were grown in an atmosphere enriched to about 650 microliters per liter of CO₂, however, photosynthetic capacity remained strongly correlated with g even though the procedure discounted any effect of variable c_i. This “residual” correlation implies the existence of a messenger in CO₂-enriched plants. Enriched CO₂ also greatly increased stomatal response to abscisic acid (ABA) injected into intact leaves. The data provide no evidence for a messenger to coordinate g with A at ambient levels of CO₂. In a CO₂-enriched atmosphere, though, ABA may function as such a messenger because the sensitivity of the system to ABA is enhanced.     

Simple Modification of the Bladder Outlet Obstruction Index for Better Prediction of Endoscopically-Proven Prostatic Obstruction: A Preliminary Study

Purpose

The bladder outlet obstruction index (BOOI), also known as the Abrams-Griffiths (AG) number, is the most widely used index for predicting BOO. However, the obstructed prostatic urethra determined by the BOOI is often inconsistent with endoscopically-proven obstruction. We assessed abdominal straining pattern as a novel parameter for improving the prediction of BOO.

Materials and Methods

We retrospectively reviewed the pressure-flow studies (PFS) and cystourethroscopy in 176 BPH/LUTS patients who were unresponsive to medical therapy. During PFS, some groups of patients tried to urinate with abdominal straining, which can increases intravesical pressure and underestimate BOOI theoretically. Accordingly, the modified BOOI was defined as (P_detQ_max+ΔP_abd)-2Q_max.

Results

Ultimately, 130 patients were eligible for the analysis. In PFS, ΔP_abd (P_abdQ_max-initial P_abd) was 11.81±13.04 cmH₂O, and it was 0–9 cmH₂O in 75 (57.7%), 10–19 cmH₂O in 23 (17.7%) and ≥20 cmH₂O in 32 (24.6%) patients. An endoscopically obstructed prostatic urethra in 92 patients was correctly determined in 47 patients (51.1%) by the original BOOI versus 72 patients (78.3%) based on the modified BOOI. Meanwhile, an “unobstructed” urethra according to the original BOOI was present in 11 patients (12.0%), whereas according to the modified BOOI, only 2 (2.1%) would be labeled as “unobstructed”. In receiver operating characteristic curves, the area under the curve was 0.906 using the modified BOOI number versus 0.849 in the original BOOI (p<0.05).

Conclusions

The change in abdominal pressure was correlated with endoscopically-proven obstruction. Our simple modification of the BOOI on the basis of this finding better predicted bladder outlet obstruction and, therefore, should be considered when evaluating BOO in patients with LUTS/BPH.     

Understanding the contribution of native tracheobronchial structure to lung function: CT assessment of airway morphology in never smokers

Background

Computed tomographic (CT) airway lumen narrowing is associated with lower lung function. Although volumetric CT measures of airways (wall volume [WV] and lumen volume [LV]) compared to cross sectional measures can more accurately reflect bronchial morphology, data of their use in never smokers is scarce. We hypothesize that native tracheobronchial tree morphology as assessed by volumetric CT metrics play a significant role in determining lung function in normal subjects. We aimed to assess the relationships between airway size, the projected branching generation number (BGN) to reach airways of <2mm lumen diameter –the site for airflow obstruction in smokers- and measures of lung function including forced expiratory volume in 1 second (FEV₁) and forced expiratory flow between 25% and 75% of vital capacity (FEF 25–75).

Methods

We assessed WV and LV of segmental and subsegmental airways from six bronchial paths as well as lung volume on CT scans from 106 never smokers. We calculated the lumen area ratio of the subsegmental to segmental airways and estimated the projected BGN to reach a <2mm-lumen-diameter airway assuming a dichotomized tracheobronchial tree model. Regression analysis was used to assess the relationships between airway size, BGN, FEF 25–75, and FEV₁.

Results

We found that in models adjusted for demographics, LV and WV of segmental and subsegmental airways were directly related to FEV₁ (P <0.05 for all the models). In adjusted models for age, sex, race, LV and lung volume or height, the projected BGN was directly associated with FEF 25–75 and FEV₁ (P = 0.001) where subjects with lower FEV₁ had fewer calculated branch generations between the subsegmental bronchus and small airways. There was no association between airway lumen area ratio and lung volume.

Conclusion

We conclude that in never smokers, those with smaller central airways had lower airflow and those with lower airflow had less parallel airway pathways independent of lung size. These findings suggest that variability in the structure of the tracheobronchial tree may influence the risk of developing clinically relevant smoking related airway obstruction.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-015-0181-y) contains supplementary material, which is available to authorized users.     

Maintenance of High Photosynthetic Rates in Mesophyll Cells Isolated from Papaver somniferum

The establishment and maintenance of high rates of photosynthetic CO₂ incorporation in mesophyll cells of Papaver somniferum (opium poppy) depend on a regime of dark and light periods immediately following isolation, as well as carefully adjusted conditions of isolation. Analysis of the incorporation pattern of ¹⁴CO₂ by the isolated cells indicates an initial “stress-response” period of approximately 20 hours characterized by increased respiratory-type metabolism and diminished photosynthesis. Under the favorable regime, this period is followed by rapid recovery and the reinstatement of a metabolic state strikingly similar to that of intact leaves in which the initial rate of CO₂ incorporation is between 110 and 175 μmoles CO₂ fixed per mg chlorophyll per hour. The photosynthetic viability of these cells can be maintained for up to 80 hours.     

Work of Breathing into Snow in the Presence versus Absence of an Artificial Air Pocket Affects Hypoxia and Hypercapnia of a Victim Covered with Avalanche Snow: A Randomized Double Blind Crossover Study

Presence of an air pocket and its size play an important role in survival of victims buried in the avalanche snow. Even small air pockets facilitate breathing. We hypothesize that the size of the air pocket significantly affects the airflow resistance and work of breathing. The aims of the study are (1) to investigate the effect of the presence of an air pocket on gas exchange and work of breathing in subjects breathing into the simulated avalanche snow and (2) to test whether it is possible to breathe with no air pocket. The prospective interventional double-blinded study involved 12 male volunteers, from which 10 completed the whole protocol. Each volunteer underwent two phases of the experiment in a random order: phase “AP”—breathing into the snow with a one-liter air pocket, and phase “NP”—breathing into the snow with no air pocket. Physiological parameters, fractions of oxygen and carbon dioxide in the airways and work of breathing expressed as pressure-time product were recorded continuously. The main finding of the study is that it is possible to breath in the avalanche snow even with no air pocket (0 L volume), but breathing under this condition is associated with significantly increased work of breathing. The significant differences were initially observed for end-tidal values of the respiratory gases (EtO₂ and EtCO₂) and peripheral oxygen saturation (SpO₂) between AP and NP phases, whereas significant differences in inspiratory fractions occurred much later (for F_IO₂) or never (for F_ICO₂). The limiting factor in no air pocket conditions is excessive increase in work of breathing that induces increase in metabolism accompanied by higher oxygen consumption and carbon dioxide production. The presence of even a small air pocket reduces significantly the work of breathing.