Pulmonary hypertension in intensive care: pathophysiology and causes.

Pulmonary hypertension is commonly encountered in Intensive Care Units and the effects on right ventricular function are often a cause for concern. The major thrust of treatment must, in the first instance, be aimed at the condition causing the hypertension. Treatment with vasodilator drugs may result in systemic hypotension which may impair coronary blood flow to the right ventricle, and may also result in an impairment of gas exchange. The inhalation of nitric oxide is an interesting new approach to treatment, but its value has not yet been evaluated in randomized controlled trials.

Effect of intraoperative inspired gas mixtures on postoperative nocturnal oxygen saturation.

Continuous postoperative nocturnal pulse oximetry was performed in 20 patients undergoing elective cholecystectomy to examine if the composition of anaesthetic gas mixtures affects postoperative gas exchange. The patients were allocated randomly to receive either nitrogen or nitrous oxide during anaesthesia, and oximetry was performed on the night before operation and the first and third nights after operation. Considerable oxygen desaturation was seen in both groups. During the first night after operation the proportion of the night during which oxygen saturation was less than 85% was greater in the nitrogen group than in the nitrous oxide group, but there was no significant difference between the mean overnight saturation values of the two groups.

The effect of dyshemoglobins on pulse oximetry: Part I, Theoretical approach and Part II, Experimental results using an in vitro test system.

Pulse oximeters are known to be inaccurate in the presence of elevated concentrations of carboxyhemoglobin and methemoglobin. This paper attempts to alleviate some of the confusion that exists between fractional and functional saturation, and to clarify the comparison of each with SpO2. A series of theoretical relationships between pulse oximeter reading (SpO2) and actual oxygen saturation (both fractional and functional) is derived using simple absorption theory. The theoretical relationships are checked using an experimental in vitro test system. This consists of a blood circuit containing a model finger, capable of simulating the pulsatile transmission signals through a real finger. Theoretical predictions and experimental results are compared and are found to agree well in the presence of carboxyhemoglobin, but less well with methemoglobin. Possible reasons are discussed.

In vitro performance test system for pulse oximeters.

An in vitro system was developed capable of testing the accuracy and reproducibility of pulse oximeter readings. The pulse oximeter probe receives signals through a pulsating blood cuvette. The development of the design of the cuvette is described. Using the final design (or 'model finger'), a comparison is made between readings from a Datex Satlite pulse oximeter (SpO2) and saturation values obtained by use of a multi-wavelength bench oximeter (SaO2). Linear regression analysis of the data gives SpO2 = 0.88 SaO2 + 11.2 (r = 0.979, p < 0.001).

Response of 10 pulse oximeters to an in vitro test system.

Pulse oximeters are often used in situations in which severe hypoxaemia may occur. We have developed an in vitro system to test the accuracy of pulse oximeter calibration. The probe of 10 different oximeters was attached to a model finger in an in vitro blood circuit, and pulse oximeter readings (SpO2) were compared with multi-wavelength in vitro oximeter readings (SO2) over a range of SO2 values from 50 to 100%. The oximeters tested varied widely in their accuracy and linearity. We conclude that the system can test the accuracy, reproducibility and linearity of response of pulse oximeter readings at low oxyhaemoglobin saturations.

Peroperative arterial hypoxaemia. The interaction between intrapulmonary shunt and cardiac output. A computer model.

A computer model of respiratory physiology was used to investigate the interaction between cardiac output and intrapulmonary shunting during anaesthesia. Significant degrees of arterial desaturation were demonstrated as the cardiac output was reduced. We suggest that volume expansion may correct some episodes of desaturation observed during anaesthesia.

Effect of ventilation with positive end-expiratory pressure on the development of lung damage in experimental acid aspiration pneumonia in the rabbit.

Sixteen anaesthetized rabbits were subjected to tracheostomy and lung damage produced by the instillation of 4.5 ml/kg hydrochloric acid (pH 1.5) into the trachea. Half of the animals were ventilated with a positive end-expiratory pressure (PEEP) of 3 cmH2O and half with a PEEP of 10 cmH2O for 5 h, the mean airway pressure being kept at 12 cmH2O by adjustment of the end-inspiratory pause time. Pressure-volume curves were recorded every hour. Although the arterial PO2 values and compliance above the inflection point on the pressure-volume curve were greater in the group submitted to 10 cmH2O PEEP, there were no significant differences between the groups in terms of survival and histological findings.

An evaluation of the Brüel and Kjaer monitor 1304.

A laboratory evaluation was performed on the Brüel and Kjaer multigas monitor 1304, incorporating a pulse oximeter. The instrument was tested for accuracy, stability, response and delay times, frequency response and the effects of water vapour, alcohol, cyclopropane and sevoflurane. The instrument's performance was found to be within or very close to the manufacturer's specifications for accuracy, stability and response and delay times. It was unaffected by water vapour and alcohol and the effect of cyclopropane on the vapour channel was lower than has been reported for other analysers. The response to sevoflurane was of the same order as that of the other vapours. A 90% response to square wave changes of gas composition was maintained up to 60 breaths.min-1 for CO2, O2, and N2O and up to 40 breaths.min-1 for the vapours when the nafion sampling tube was used.

Tracheal tube resistance and airway and alveolar pressures during mechanical ventilation in the neonate.

The relationship between peak airway pressure, alveolar pressure and respiratory frequency was calculated for the range of compliances and airway resistances which might be encountered during mechanical ventilation of a 3-kg neonate. The pressure/flow relationships of 2.5, 3.0, 3.5 and 4-mm tracheal tubes were determined at a series of flows from 0.5 to 4 litres/minute. Peak airway and alveolar pressures were then measured at various frequencies and inspiratory:expiratory ratios with the tubes incorporated in a model lung. Large differences between peak airway and alveolar pressures developed when frequency was increased or inspiratory time decreased; the differences were greatest with the smaller tubes. Shortening expiratory time by increasing the frequency or altering the inspiratory:expiratory ratio resulted in increased end-expiratory pressure because of incomplete emptying of the lung.

Delayed detection of hypoxic events by pulse oximeters: computer simulations.

There is a variable delay between a reduction in alveolar PO2 and the decrease in arterial oxygen saturation recorded on a pulse oximeter. The decrease in arterial oxygen saturation in response to disconnexion of a paralysed patient from the breathing system, oxygen supply failure with continued mechanical ventilation and disconnexion of the fresh gas supply to Mapleson D and circle absorption breathing systems were studied by simulations on the MacPuf computer model of the cardiorespiratory system. The simulations revealed that there were marked differences between the rate of arterial desaturation which resulted from each of the three types of oxygen supply failure and that arterial oxygen saturation may reach dangerous levels before a pulse oximeter alarm is activated.