Biomedical subjects
Publications and source records attributed to C Ray.
A variety of technical decisions are required for the proper selection and safe and efficacious application of high-frequency jet ventilation (HFJV). Criteria for analyzing the performance of an HFJV system are presented, along with discussions of some of the more common respiratory measurements and their applicability to HFJV.
The consensus of available studies indicates that high-frequency jet ventilation (HFJV) can adequately ventilate animals in respiratory failure, although a clear superiority to volume-cycled ventilation (VCV) cannot be established. HFJV is probably useful in the presence of airway disruption and in tracheal or pulmonary surgery. Clinical trials and additional bench and animal studies must be performed, to reach a full understanding of the potential benefits of this technique.
Data from a prospective randomized investigation comparing volume-cycled ventilation and high-frequency jet ventilation were reexamined to determine whether improvement of respiratory and hemodynamic function, as well as ultimate outcome (death or survival), could be predicted early in the course of the disease. End points were selected for the ratio of the arterial oxygen pressure over the fractional concentration of oxygen in the inspired gas (PaO2/FIO2), the arterial oxygen saturation (SaO2), the arterial carbon dioxide tension (PaCO2), and the cardiac index. Patients were assigned to "success" or "failure" groups, according to the values recorded for those end points 24 hours after institution of mechanical ventilation. Values obtained from initiation of mechanical ventilation to 16 hours later were divided into four time groups. Differences between patients who "succeeded" and "failed" were compared at each time interval. Ultimate outcome was also compared. The PaCO2 and cardiac index were poor predictors of survival. Early values did not foretell the progression of these variables. The PaO2/FIO2 and SaO2 effectively discriminated, at all time intervals, between patients who succeeded and failed on volume-cycled ventilation. On high-frequency jet ventilation, significant differences were evident only after eight hours of support. With both types of ventilator, patients who reached the end point of oxygenation at 24 hours survived in far greater numbers than those who did not. On the basis of this investigation, it appears justified to attempt high-frequency jet ventilation in patients who do not rapidly improve on volume-cycled ventilation. Institution of high-frequency jet ventilation as the initial support method may not be advisable, since failure does not become apparent for many hours.
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Cholinergic receptors in pacemaker and contractile tissue of heart were studied in an isolated sinoauricular (s.a.) node preparation of cat containing crista terminalis. Acetylcholine (ACh), 10(-9) - 10(-5), caused concentration dependent negative inotropic and negative chronotropic effects, the former being more prominent than the latter. Atropine (10(-10) - 10(-4)M) prevented these inhibitory effects of ACh in a competitive manner. No cardioexcitatory effect of ACh was seen in these preparations treated with up to 10(-4)M atropine. It is concluded that the pacemaker cells of s.a. node and contractile atrial cells in cat contain inhibitory muscarinic receptors but no ACh sensitive excitatory nicotinic receptors. The contractile cells of atrium are more sensitive than the pacemaker cells of s.a. node of cat to the inhibitory effects of ACh.
The principle of jet injector indicates that large tidal volumes may be delivered on high frequency jet ventilation (HFJV) without increasing airway pressure. Fifteen dogs were ventilated on HFJV in 2 separate experiments. In the first one, tidal volume was maintained constant at 10 ml/kg, while PEEP, respiratory rate, and cannula size were changed in 16 different experimental conditions. In the second experiment, driving pressure was progressively increased from 5 to 45 psig, and PEEP, respiratory rate, and injector size were changed in 32 experimental conditions. Mean airway pressure, tidal volume, driving pressure, thoracic aortic mean pressure, and abdominal aortic mean pressure were the variables measured. Tidal volume linearly increased with driving pressure, while airway pressure only increased when tidal volume exceeded 25 ml/kg. Blood pressure was inversely related to mean airway pressure. Tidal volume was twice as high with the 1.62 mm injector, as compared to the 1.06 mm injector, although resistances are 6 times higher with the smaller injector. The difference is related to the higher entrainment, which is observed when jet flow velocity increases, as is the case when the injector cannula is smaller. The experiments confirmed that HFJV follows the physical principles of jet mixing and entrainment.
Anecdotal observations suggest that high frequency jet ventilation (HFJV) is beneficial in major airway disruption. Quantitative evaluation is, however, unavailable. In 12 healthy mongrel dogs, a tracheal window of increasing size, from 0.5 x 1 cm to 1.5 x 2 cm, was opened. Dogs were supported on volume-cycled ventilation (VCV) and on HFJV, using injector cannulas of 1.06 and 1.62 mm internal diameter. The tracheal window was then closed and an upper lobectomy performed, followed by total pneumonectomy. Arterial blood gases were obtained after 10 min in each experimental condition. VCV could maintain life-supporting blood gases only with the tracheal window of 0.5 x 1 cm. HFJV, delivered with a 1.06-mm injector cannula, was adequate with a tracheal window of 1 x 1 cm, or after a lobectomy. In all experimental conditions, HFJV delivered with a 1.62-mm injector effectively maintained alveolar ventilation and arterial oxygenation. Gas transport on HFJV is based, in part, on the principles of jet mixing and entrainment; increasingly large tidal volumes can be delivered under conditions of low and constant pressure. Air leaks through pathological openings remain constant even when tidal volume is increased, so that alveolar ventilation can be adequately maintained.
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Because mammalian distal nephron segments with both calcitonin- and antidiuretic hormone- (ADH) sensitive adenylate cyclase activity have been described, in vivo and in vitro experiments were performed to study the effect of calcitonin on rat distal nephron water permeability. Calcitonin 1 and 0.1 U/ml, but not 0.01 U/ml, significantly increased the diffusional water permeability in the isolated papillary collecting duct by 15 and 11%, respectively. However, this effect was small when compared with a 68% increase with a supramaximal concentration of ADH (from 4.0 +/- 0.3 to 6.7 +/- 0.9 microns/s; n = 6, P less than 0.01). The normal increase in water permeability with increasing concentration of ADH (0.02 and 0.2 mU/ml) was depressed by the previous addition of calcitonin (1 U/ml) to the bath but was unaltered with the supramaximal ADH concentration (2 mU/ml). Verapamil, a compound that antagonizes cellular calcium entry, did not alter the effect of calcitonin on diffusional water permeability. Calcitonin in concentrations of 0.05, 0.5, and 5 U/ml produced a significant reduction in urine flow and free water clearance. Pretreatment with calcitonin in these concentrations inhibited the antidiuretic action of ADH. These studies suggest that calcitonin acts as a partial agonist to ADH within the distal nephron. It is unclear whether such an action represents a physiological or a pharmacological effect.
Three hundred nine patients were randomly allocated to two ventilatory protocols; 157 patients were supported with a volume-cycled ventilator (VCV) (Bear Medical BEAR 1) and 152 with a high-frequency jet ventilatory (HFJV) developed at our institution. The two ventilators were compared for safety, reliability, ease of use, and efficacy in maintaining gas exchange. On VCV, end points of therapy were: fractional concentration of oxygen in the inspired gas (FIo2) less than or equal to 0.40; arterial oxygen pressure (PaO2) greater than or equal to 70 mm Hg; cardiac index (CI) greater than or equal to 3.5 L/min/sq m; and spontaneous respiratory rate less than or equal to eight breaths per minute. On HFJV, end points were: FIo2 less than or equal to 0.45; arterial oxygen saturation greater than or equal to 0.90; and CI greater than or equal to 3.5 L/min/sq m. Spontaneous ventilation and pulmonary venous admixture reduction were the goals on VCV, with oxygen transport the goal on HFJV, Total duration of use of the ventilators was approximately 800 days with both types of devices; there were no technical failures, and the incidence of barotrauma was less than 5 percent. The end point of mechanical ventilation was reached by a significantly higher percentage of the patients randomized to HFJV. Patients who failed to reach the therapeutic goal within 24 hours were crossed over to the other form of support. Those crossed from VCV to HFJV improved more rapidly and in greater number than those crossed from HFJV to VCV. When survival and total duration of stay in the intensive care unit were considered, there was no difference between VCV and HFJV. Considering data on gas exchange, VCV provided a higher PaO2 at equivalent positive end-respiratory pressure than HFJV. Alveolar ventilation was slightly better on HFJV. Differences were statistically but not clinically significant. On HFJV, oxygenation and ventilation were maintained with lower peak inspiratory pressures and smaller tidal volumes than those required for VCV. This investigation proves that HFJV is a safe and reliable method to provide mechanical support which does not, at this time, offer obvious benefits over VCV.
We have demonstrated the feasibility of using a compact dedicated mass spectrometer to monitor end-tidal xenon concentration in human subjects during stable xenon computerized tomography measurements of regional cerebral blood flow. End-tidal carbon dioxide concentration is monitored simultaneously and noninvasively without degrading the dynamic response to xenon. For clinical regional cerebral blood flow studies we employed a Nuclide 3-60-G Sectorr mass spectrometer with a 3 in radius, 60 degrees magnetic sector and a variable (0-5000 V) ion accelerating potential. The required high vacuum (10(-7) Torr) was achieved and maintained by means of a turbomolecular pump. A needlemetering valve was incorporated into an anesthesia mask connector, and exhaled gases were transported to the mass spectrometer via a 6 ft length of Teflon tubing (1/16 in i.d.). Molecular flow conditions between the sample and analysis chambers were provided by use of a gold foil leak (0.0005 in. hole). At an inlet pressure of 400 m Torr (achieved by means of the needle valve), the inlet system was characterized by a gas transport lag-time of 1.3 s and a rise-time constant of 85 ms. Xenon (doubly charged ion: m/z 68) and carbon dioxide (doubly charged ion: m/z 22) were monitored alternately at 75 ms intervals. Our experience with mass spectrometry has demonstrated the feasibility of using a compact dedicated instrument for accurately and non-invasively monitoring end-tidal xenon concentration in a clinical setting.
Coping is action directed at the resolution or mitigation of a problematic situation. There are a number of ways in which this may be attempted, and a number of ways of classifying coping strategies. This paper presents a simple schema of six coping themes, ordered in terms of their defensiveness and the degree of attempted personal control which they imply. They comprise rejection, control, resignation, dependency, avoidance and minimization, and characterize the meaning or qualitative 'style' of the individual's response, rather than the formal characteristics of the strategies employed. Data from studies of breast cancer and surgical patients are cited to illustrate the substance of the themes.
High-frequency jet ventilation (HFJV) described a technique of mechanical respiratory support based on the delivery of gases under conditions of constant flow and low pressure. Among the benefits ascribed to HFJV are lessened interference with hemodynamic function and reduced danger of barotrauma. The theoretical and technical aspects of HFJV are discussed and the clinical experience with 39 patients in respiratory failure reported. Synchronization of HFMV with heart rate was attempted in three patients. Cardiac output and ejection fraction increased in all of them. At present, results suggest that HFJV may be the ideal form of support for patients with major airway disruption. The available data also indicated that extensive clinical trials are warranted to define advantages and limits of this form of ventilation.
The effect of prostaglandin on diffusional water permeability has been studied in collecting ducts in an isolated rat papilla. PGE2 increased water permeability. The effect was significant at a concentration of 10(-8) mol 1(-1) and was maximal with a concentration of 10(-6) mol 1(-1). The maximal increment of 0.94 +/- 0.10 (SEM) micron s-1 was approximately half that produced by maximal stimulation with antidiuretic hormone (2.18 +/- 0.12 micron s-1). A concentration of 10(-8) mol 1(-1) produced an increase in basal water permeability and 24 mu unit ml-1 ADH, which without PGE2 present gave a similar increase, had no incremental effect. ADH 100 mu unit ml-1 increased permeability to a value similar to that observed in the absence of PGE2. Thus PGE2 and ADH both increase water permeability but the increments are not additive. Indomethacin in a concentration that inhibited prostaglandin production altered the response of the collecting duct to ADH. The dose response curve was shifted to the left and the maximal increase in water permeability and the lowest dose at which a response occurred took place at concentrations less than 1/2 those required in its absence. Prostaglandins influence the action of ADH and it is likely that in life they regulate and modulate the change in water permeability induced by anti-diuretic hormone.
The effects of atropine and glycopyrrolate on anatomical dead space, one and three second forced expiratory volume, maximal expiratory flow rate, and total forced expiratory volume were determined in ten healthy volunteers. Using Fowler's single breath nitrogen analyzing technique, atropine was found to increase dead space by 19.2 per cent at one hour, declining to 11.02 per cent at four hours. Glycopyrrolate increased dead space by 21.57 per cent at one hour, 29.28 per cent at two hours, and 26.65 per cent at four hours. When compared to the effects of saline control injection, the dead space increases are significant. The difference between glycopyrrolate and atropine is significant only at four hours. Increases in maximal expiratory flow rate induced by atropine and glycopyrrolate were significant at one-half hour, while atropine alone induced a significant increase in one second forced expiratory volume. Three second forced expiratory volume and total forced expiratory volume were not significantly altered.
There is little evidence of a curvilinear relationship between pre-operative emotionality and post-operative adjustment, as predicted by a model which supposes that moderate preoperative anxiety assists adjustment. This paper suggests that the negative affect, or stress, associated with the work of worry should be distinguished from the active coping orientation which it also implies. In this study stress and arousal were assessed pre-operatively in a sample of cholecystectomy patients, and correlations between these scores and various indices of post-operative adjustment were computed. Stress before surgery was positively related to stress and pain experienced post-operatively. Arousal, by contrast, was negatively related to pain, medications and period before discharge. Female patients had higher stress scores than the males, while the direction of the difference was reversed in te case of arousal. These findings are interpreted as support for the significance of the role of coping orientation, as represented by arousal, in promoting adjustment, with emotionality or stress playing a less significant and even negative role.