KHAN RAFAY ALI (CA)
SOBCZYK OLIVIA (CA)
DUFFIN JAMES (CA)
FISHER JOSEPH ARNOLD (CA)
| US20040206354A1 | 2004-10-21 | |||
| US20170238841A1 | 2017-08-24 | |||
| US20030100843A1 | 2003-05-29 |
| We claim: 1. A method of determining alveolar dead space of a subject, the method comprising: measuring an end tidal partial pressure of carbon dioxide during a sequence of normal breaths of the subject; during a sequence of deep breaths by the subject, delivering a first volume of a first gas to the subject over a first portion of each inspiration by the subject, the first volume being less than or equal to an expected alveolar volume of the subject when the subject is breathing normally, and delivering a second volume of a second gas to the subject over a second portion of each inspiration, wherein the second gas comprises a neutral gas; measuring an end tidal partial pressure of carbon dioxide during the sequence of deep breaths; and computing the alveolar dead space using the end tidal partial pressure of carbon dioxide measured during the sequence of normal breaths and the end tidal partial pressure of carbon dioxide measured during the sequence of deep breaths. 2. The method of claim 1 , comprising computing the alveolar dead space based on a ratio of the end tidal partial pressure of carbon dioxide measured during the sequence of normal breaths to an alveolar partial pressure of carbon dioxide of the subject, wherein the alveolar partial pressure of carbon dioxide of the subject is considered to be the end tidal partial pressure of carbon dioxide measured during the sequence of deep breaths. 3. The method of claim 2 wherein: the first gas has a partial pressure of carbon dioxide that is less than a partial pressure of carbon dioxide of a gas exhaled by the subject; and the second gas has a partial pressure of carbon dioxide corresponding to the partial pressure of carbon dioxide of the gas exhaled by the subject. 4. The method of claim 3, wherein the first volume is less than or equal to an expected alveolar volume of the subject when the subject is breathing normally. 5. Use of the method of claim 1 in an assessment of a medical condition selected from a group consisting of heart failure, congestive heart failure, adult respiratory distress syndrome, lung function after lung transplant, lung function after transplant, sepsis, trauma, and pulmonary and systemic disease. 6. A device for determining alveolar dead space of a subject, the device comprising: a user interface device; a gas blender to receive source gases; and a processor connected to the user interface device and the gas blender to control the supply of gas to the subject, wherein the processor is to: control the gas blender to deliver a first gas and a second gas sequentially to the subject during a period of deep breathing by the subject, wherein a volume of the first gas is about an expected alveolar volume of the subject when the subject is breathing normally, wherein the second gas is a neutral gas, and wherein the first gas has a partial pressure of carbon dioxide that is less than that of the second gas; measure an end tidal partial pressure of carbon dioxide of the subject during the period of deep breathing; compute a representation of alveolar dead space using the end tidal partial pressure of carbon dioxide measured during deep breathing and an end tidal partial pressure of carbon dioxide of the subject obtained during normal breathing; and output the indication of the alveolar dead space at the user interface. 7. The device of claim 6, wherein the processor is further to: deliver the first gas and the second gas sequentially to the subject during a period of normal breathing; and measure the end tidal partial pressure of carbon dioxide of the subject during the period of normal breathing. 8. The device of claim 6, wherein the processor is to compute the representation of alveolar dead space based on a ratio of the end tidal partial pressure of carbon dioxide of the subject obtained during normal breathing to an alveolar partial pressure of carbon dioxide of the subject, wherein the alveolar partial pressure of carbon dioxide of the subject is considered to be the end tidal partial pressure of carbon dioxide measured during deep breathing. 9. The device of claim 6, wherein the processor is to compute the representation of alveolar dead space as a ratio of the alveolar dead space to a volume of gas entering the alveoli. 10. Use of the device of claim 6 in an assessment of a medical condition selected from a group consisting of heart failure, congestive heart failure, adult respiratory distress syndrome, lung function after lung transplant, lung function after transplant, sepsis, trauma, and pulmonary and systemic disease. |
Gas Delivery
CROSS-REFERENCE TO RELATED APPLICATION
[0001] This application claims priority to US provisional app. ser. no. 62/941,837, filed Nov. 28, 2019, and incorporated herein by reference.
BACKGROUND
[0002] The mammalian lung includes two functional components: 1) airways for convection of gases to and from 2) the sac-like alveoli. The alveolar walls are surrounded by a mesh of tiny blood vessels called capillaries. Gases such as oxygen and carbon dioxide diffuse between the gas in the alveoli and blood in the capillaries.
[0003] The airways are composed of a set of branching thick walled tubes that do not engage in gas exchange with the blood, generally termed “dead space.” Airway dead space is specifically referred to as the “anatomical dead space.”
[0004] Some of the alveoli also do not participate in gas exchange. This may be due to their walls being too thickened to readily allow diffusion, their capillaries having reduced or absent perfusion of blood, or their lacking capillaries altogether. This is called “alveolar dead space.”
SUMMARY
[0005] According to one aspect of the present disclosure, a method of determining alveolar dead space of a subject includes measuring an end tidal partial pressure of carbon dioxide during a sequence of normal breaths of the subject and, during a sequence of deep breaths by the subject, delivering a first volume of a first gas to the subject over a first portion of each inspiration by the subject. The first volume is less than or equal to an expected alveolar volume of the subject when the subject is breathing normally. The method further includes delivering a second volume of a second gas to the subject over a second portion of each inspiration. The second gas includes a neutral gas. The method further includes measuring an end tidal partial pressure of carbon dioxide during the sequence of deep breaths and computing the alveolar dead space using the end tidal partial pressure of carbon dioxide measured during the sequence of normal breaths and the end tidal partial pressure of carbon dioxide measured during the sequence of deep breaths.
[0006] The method may further include computing the alveolar dead space based on a ratio of the end tidal partial pressure of carbon dioxide measured during the sequence of normal breaths to an alveolar partial pressure of carbon dioxide of the subject. The alveolar partial pressure of carbon dioxide of the subject is considered to be the end tidal partial pressure of carbon dioxide measured during the sequence of deep breaths.
[0007] The first gas may have a partial pressure of carbon dioxide that is less than a partial pressure of carbon dioxide of a gas exhaled by the subject.
[0008] The second gas may have a partial pressure of carbon dioxide corresponding to the partial pressure of carbon dioxide of the gas exhaled by the subject.
[0009] The first volume may be less than or equal to an expected alveolar volume of the subject when the subject is breathing normally.
[0010] According to another aspect of the present disclosure, the method may be used in an assessment of a medical condition selected from a group consisting of heart failure, congestive heart failure, adult respiratory distress syndrome, lung function after lung transplant, lung function after transplant, sepsis, trauma, and pulmonary and systemic disease.
[0011] According to another aspect of the present disclosure, a device for determining alveolar dead space of a subject includes a user interface device, a gas blender to receive source gases, and a processor connected to the user interface device and the gas blender to control the supply of gas to the subject. The processor is to control the gas blender to deliver a first gas and a second gas sequentially to the subject during a period of deep breathing by the subject. A volume of the first gas is about an expected alveolar volume of the subject when the subject is breathing normally. The second gas is a neutral gas. The first gas has a partial pressure of carbon dioxide that is less than that of the second gas. The processor is further to measure an end tidal partial pressure of carbon dioxide of the subject during the period of deep breathing, compute a representation of alveolar dead space using the end tidal partial pressure of carbon dioxide measured during deep breathing and an end tidal partial pressure of carbon dioxide of the subject obtained during normal breathing, and output the indication of the alveolar dead space at the user interface.
[0012] The processor may deliver the first gas and the second gas sequentially to the subject during a period of normal breathing and measure the end tidal partial pressure of carbon dioxide of the subject during the period of normal breathing.
[0013] The processor may compute the representation of alveolar dead space based on a ratio of the end tidal partial pressure of carbon dioxide of the subject obtained during normal breathing to an alveolar partial pressure of carbon dioxide of the subject. The alveolar partial pressure of carbon dioxide of the subject is considered to be the end tidal partial pressure of carbon dioxide measured during deep breathing.
[0014] The processor may compute the representation of alveolar dead space as a ratio of the alveolar dead space to a volume of gas entering the alveoli.
[0015] According to another aspect of the present disclosure, the device may be used to make an assessment of a medical condition selected from a group consisting of heart failure, congestive heart failure, adult respiratory distress syndrome, lung function after lung transplant, lung function after transplant, sepsis, trauma, and pulmonary and systemic disease.
BRIEF DESCRIPTION OF THE DRAWINGS
[0016] FIG. 1A is a graph of a Bohr dead space.
[0017] FIG. IB is a graph of an Enghoff dead space.
[0018] FIG. 2 is a graph of a Fowler dead space.
[0019] FIG. 3 is a block diagram of a device to measure an alveolar dead space of a subject.
[0020] FIG. 4 is a flowchart of a method of measuring an alveolar dead space of a subject. [0021] FIG. 5A is a schematic diagram of gas distribution, equilibration, and mixing in relation to end tidal concentration of carbon dioxide in a two-region alveolar model under normal breathing.
[0022] FIG. 5B is a schematic diagram of gas distribution, equilibration, and mixing in relation to end tidal concentration of carbon dioxide in a two-region alveolar model under sequential gas delivery with normal or spontaneous breathing.
[0023] FIG. 6 is a schematic diagram of gas distribution, equilibration, and mixing in relation to equilibration of arterial carbon dioxide and carbon dioxide in exhaled gas at end of expiration in a two-region alveolar model under sequential gas delivery with deep breathing.
[0024] FIG. 7 is a plot of a measured ratio of alveolar dead space to volume of gas entering the alveoli plotted as partial pressure of carbon dioxide in exhaled gas at end of expiration versus time.
DETAILED DESCRIPTION
[0025] Alveolar dead space (VDalv) is an important parameter in the assessment of lung diseases such as acute respiratory distress syndrome (ARDS), pulmonary embolization, chest trauma, prognosis in major surgery, and lung transplantation, as well as in the investigation of exercise tolerance and sport performance. It is also thought to be a major contributor to the proportional increased breathing in response to exertion in patients with heart failure.
[0026] It is difficult to measure precisely VDalv. However, it can be measured in combination with anatomical dead space (VDanat) as the “physiological dead space” (VDphys).
[0027] The volume of the physiological dead space (VDphys) can be calculated from how much it dilutes carbon dioxide (CO2) in the perfused alveoli in a collection of exhaled gas. To do this, all the gas expired in, say, one minute is collected in a bag and then the fractional partial pressure of CO2 (FCO2) in the bag is measured by measuring the partial pressure of CO2 (PCO2) specific to the barometric pressure (PB), where:
[0028] FCO2 = PCO2 / PB [0029] The concentration of CO 2 in the bag comes from all parts of the lung, so it is called the “mixed expired concentration” (FECO 2 ). The volume of the dead space (VD) can be measured or estimated based on comparing the mixed expired concentration (FECO 2 ) to the concentration of CO 2 in the inspired gas (FICO 2 , 0%) and to the concentration of CO 2 in the alveoli (FACO 2 ), which is assumed to be the concentration measured from the end of a breath, i.e., the end tidal concentration of CO 2 (FETCCF). Note that the end tidal partial pressure of carbon dioxide (PETCCF) cannot be equal to the partial pressure of CO 2 in the alveoli (PACO 2 ) as it is a mixture of the PACO 2 and inspired gas coming out of the alveolar dead space (VDalv). However, as the PACO 2 is not otherwise measurable using conventional methodologies, this simplifying assumption is made. Another approximation of PACO 2 is the partial pressure of CO 2 in arterial blood (PaCCF).
[0030] Two currently accepted ways of calculating physiological dead space (VDphys) are the Bohr method (FIG. 1A) and the Enghoff method (FIG. IB). The subject inhales air and exhales into a container for multiple breaths. The volume of the bag is the sum of the volume of inspired gas or tidal volume (VT). The partial pressure of carbon dioxide (PCO 2 ) in the bag is a mixture of PCO 2 from alveoli and all of the dead space, and is called mixed expired PCO 2 (PECO 2 ).
[0031] VT FECO 2 = (VT - VDphys) x FACO 2 (Bohr dead space)
[0032] VT x FECO 2 = (VT - VDphys) x FaC0 2 (Enghoff dead space)
[0033] For the Bohr dead space, the alveolar partial pressure of carbon dioxide (PACO 2 ) is assumed to be that corresponding to halfway along the expiratory plateau (Phase III). For the Enghoff dead space, PACO 2 is assumed to be equal to the partial pressure of CO 2 in arterial blood (PaC0 2 ). FIGs. 1A and IB show that PaC0 2 is usually greater than the end tidal partial pressure of CO 2 (PETC02) resulting in the calculation of a larger physiological dead space (VDphys) (VDaw is the volume of the airways, or VDanat). In addition, the substitution of PaC02 for PAC02 by Enghoff produces confusion in the interpretation of the mechanisms of dead space production. The substitution is only valid in an ideal lung, one with perfect ventilation to perfusion (V / Q) matching for all units, which cannot be expected in practice. [0034] If physiological dead space (VDphys) can be determined, as above, then alveolar dead space (VDalv) can be computed as VDphys - VDanat, provided that anatomical dead space (VDanat) can also be determined.
[0035] As mentioned, anatomical dead space (VDanat) consists of the volume of the conducting airways, such as the trachea and bronchi. During inhalation, gas flows along the trachea, bronchi and eventually (mostly by diffusion) into the alveoli. The first gas inhaled during a breath reaches the alveoli. In the alveoli, it undergoes gas exchange with capillary blood to the point of equilibration so that the partial pressure of CO2 and the partial pressure of O2 of gas in the alveoli and capillary blood are the same. At the end of the expiration, the last approximately 150 ml of the breath remains in the anatomical dead space (VDanat). At the beginning of the next inspiration, the gas of the VDanat is the first to enter into the alveoli and joins with the gas in the functional residual capacity (FRC).
[0036] The traditional way to measure anatomical dead space (VDanat) is to take a breath of pure oxygen and exhale while measuring flow and nitrogen concentration. Nitrogen concentration rises when the VDanat flow passes the sensor measuring nitrogen concentration. This is the Fowler dead space.
[0037] FIG. 2 shows Fowler’s illustration of the measurement of anatomical dead space, plotting exhaled concentration of nitrogen (C) following an inspired breath of 100% oxygen against exhaled volume (Vexp), where Cinsp represents the inspired nitrogen concentration (0%) and Calv represents the alveolar concentration of nitrogen. The vertical dashed line is positioned so that a and b subsume equal areas, and the intersection of the dashed line with the exhaled volume axis defines Vds, the anatomical dead space volume. Fowler noted that VDanat was very close to 1 ml/lb in both men and women. With deep breaths, VDanat may enlarge a little.
[0038] The Fowler method is but one example and other methods are suggested. However, many of such methods of measuring anatomical dead space (VDanat) have poor rationale and have not — indeed, cannot — be validated against any standard. Moreover, these measures become less accurate the more mixing there is of the alveolar gas with gas in the alveolar dead space (VDalv) and anatomical dead space (VDanat). [0039] The conductive airway-alveolar interface constitutes the limit between the convective and diffusive transports of CO 2 within the lungs. As each terminal bronchial cluster has its own interface due to the asymmetry of airways, and due to mixing and diffusion of gas between that from the bronchi and that in the alveoli, there has to be a broad (as opposed to an abrupt) transition of the partial pressure of CO 2 (PCO 2 ) as measured at the sensor during an expiration. This gives rise to the slope in the transition from anatomical dead space gas to alveolar gas (also called Phase II slope). As a result, the airway-alveolar interface and thus the measure of the anatomical dead space (VDanat) is placed, merely by convention and for convenience ( i. e. , not by scientifically verified methods), at the midpoint of this Phase II. Engel and Paiva have provided theoretical evidence for this assumption, using mathematical simulation, yet it remains an assumption and not a measurement. The same extent of uncertainty applies to the calculation of alveolar dead space (VDalv). This lack of an accepted “gold standard” limits the ability to compare methodologies for anatomical and thus alveolar dead space measurement. Thus, confidence in measures reflect only the confidence in the measuring method.
[0040] Hence, while it is possible to measure physiological dead space (VDphys) and anatomical dead space (VDanat), as discussed above, so as to compute alveolar dead space (VDalv), this approach may be cumbersome, time-consuming, invasive, and inaccurate.
[0041] The present disclosure provides convenient, quick, non-invasive, and accurate techniques for the measurement of alveolar dead space (VDalv), specifically techniques that use direct measurement, so as to provide a gold standard that is mainly or only limited by precision in measurement.
[0042] A glossary of the main terms/abbreviations used in this disclosure is given below:
[0043] FACO 2 — Fractional alveolar partial pressure of CO 2 ; may be computed as PACO 2 / PB [0044] FaCCF — Fractional arterial partial pressure of CO 2 [0045] fB — Breathing frequency
[0046] FCO 2 — Fractional partial pressure of CO 2 ; the partial pressure of CO 2 / PB [0047] FECO 2 — Fractional mixed expired partial pressure of CO 2 ; PECO 2 / PB [0048] FICO2 — Fractional concentration of inspired CO2
[0049] FRC — Functional residual capacity; that volume of gas in the lung at the end of a normal exhalation. The partial pressures of O 2 and CO 2 in the FRC are equal to those in the capillary blood
[0050] PACO 2 — Alveolar partial pressure of CO 2 ; the partial pressure of CO 2 in alveoli that has equilibrated with the partial pressure of CO 2 of the blood in the alveolar capillaries
[0051] PaCC>2 — Partial pressure of CO2 in arterial blood
[0052] PB — Barometric pressure
[0053] PCO 2 — Partial pressure of CO 2
[0054] PECO 2 — Mixed expired partial pressure of CO 2 ; for example, the partial pressure of CO 2 in a bag containing several exhaled breaths; the net partial pressure of CO 2 after mixing alveolar gas and dead-space gas
[0055] PETCCE — Partial pressure of carbon dioxide in exhaled gas at end expiration
[0056] PET02 — Partial pressure of oxygen in exhaled gas at end expiration
[0057] PvCC> 2 — Mixed venous partial pressure of CO 2 which is the PCO 2 in the blood returning from various parts of the body, mixed together; this is the PCO 2 of the blood entering the alveoli.
[0058] Q — Cardiac output; perfusion (L/min)
[0059] Qs — Shunt flow; that part of pulmonary blood flow that does not undergo gas exchange before becoming part of the arterial blood (L/min)
[0060] SGD — sequential gas delivery; inspiratory gas is divided into a volume of first gas (Gl), which is intended to enter the alveoli, followed by a second gas (G2), the volume of which is at least that of the anatomical dead space (VDanat). The composition of second gas (G2) may be equivalent to gas that equilibrated with capillary blood in alveoli on the previous breath.
[0061] VA — Volume of gas entering the alveoli [0062] VA — Alveolar ventilation; volume of gas per minute in the alveoli, whether perfused or not. The latter is the ventilation of the alveolar dead space (VDalv)
[0063] VE — Minute ventilation; total volume of gas breathed per minute
[0064] VDphys — Physiological dead space; the part of the tidal volume VT that does not undergo gas exchange; it is composed of anatomical dead space (VDanat) and alveolar dead space (VDalv)
[0065] VDalv — Alveolar dead space; the volume of gas that enters alveoli but does not undergo gas exchange. This is because these alveoli are not perfused. This part of the lung has a high ratio of ventilation to perfusion, i.e., a high V / Q. In reality, there is some ventilation and some perfusion in most alveoli. If the gas reaches a region where some gas exchange takes place, that gas is functionally divided into the equivalent of a volume that has undergone full gas exchange (matched V / Q) and a volume that has undergone no gas exchange (high VE / Q, i.e., VDalv).
[0066] VDanat — Anatomical dead space; the volume of the lung incapable of gas exchange such as trachea, major bronchi, and branch bronchi down to alveolar ducts leading to the alveoli; the VDanat is about 2 ml/kg weight (see FIG. 1 )
[0067] VT — Tidal volume; the volume of inspired gas (mL)
[0068] VTalv — Alveolar tidal volume; the volume of gas distributed each breath to the alveoli, whether or not involved in gas exchange
[0069] NOTE: Fractional concentration is equal to the partial pressure of the gas divided by the barometric pressure (PB), e.g., for CO 2 , FETC02 = PETC02 / PB. When a fractional concentration of CO 2 is multiplied by a gas volume, it results in a volume of CO 2 . As barometric pressure is readily measurable, fractional concentration and partial pressure are used interchangeably herein.
[0070] NOTE: In general, upper case “A” indicates alveolar and lower case “a” indicates arterial.
[0071] The matching of ventilation and perfusion (V / Q) in the alveoli is crucial for providing adequate gas exchange and optimizing O 2 uptake and CO 2 elimination, as well as regulating the optimal partial pressures of each in the arterial blood. An adequate partial pressure of O 2 in arterial blood (PaC ) is required to provide a partial pressure gradient for diffusion of O 2 into the tissues. An optimal partial pressure of CO 2 (PCO 2 ) is required to maintain pH in the blood and intracellular fluid for enzymes to work at optimal efficiency. The latter is controlled by feedback loops between blood partial pressure of CO 2 (PaCC ) as sensed by the carotid bodies, and tissue partial pressure of CO 2 (PCO 2 ) in the medulla of the brain and the consequent adjustment of minute ventilation (VE).
[0072] In the perfused alveoli, the partial pressures of CO 2 and O 2 (PCO 2 and PO 2 ) equilibrate with the blood, resulting PCO 2 equal to that in the arterial blood (PaCC ), say, about 40 mmHg. The PCO2 in the alveoli is termed alveolar PCO2 and designated PACO2.
[0073] If there were no blood that crossed from mixed venous side to the arterial side without undergoing gas exchange (i.e., shunt flow Qs), the arterial and alveolar partial pressures of CO 2 (PaC0 2 and PACO 2 ) would be equal. To the extent that there is Qs, PaCC may exceed PACO 2 . As Qs is almost always small, and the CO 2 content in the mixed venous blood is very close to that in the arterial blood, despite the difference in PCO 2 , except for very large shunt flow, there is very little difference between PaCC and PACO 2 .
[0074] If blood flow is reduced to a part of the lung, for example by blockage of branches of the pulmonary artery such as by blood clot embolization ( e.g ., blocking off a major blood vessel to a part of the lung), the ventilation to that part of the lung is wasted (i.e., that part of the lung has high V / Q). The blood that would have perfused that lung is redistributed to other parts of the lung where ventilation is intact. In these alveoli, where perfusion and ventilation are intact, the alveolar gas equilibrates with the capillary blood such that the alveolar partial pressure of CO 2 (PACO 2 ) is normal, as then is the arterial partial pressure of CO 2 (PaCC ).
[0075] In the alveoli that are not perfused, PCO 2 remains a function of the gas that was left in that space at the end of exhalation, plus what was inhaled. The latter consists of an initial volume of equilibrated gas left in the anatomical dead space (VDanat) from the previous breath, and room air with a partial pressure of CO 2 of 0 mmHg. At end inhalation, these gases mix, but no equilibration takes place. On exhalation, the end tidal partial pressure of CO 2 (PETC02) consists of a mixture of alveolar gas from perfused alveoli (PCO 2 is about 40 mmHg) and gas from the alveolar dead space (VDalv), PCO 2 of about 0 mmHg, mixed together. The greater the contribution from the alveolar dead space (VDalv), the lower the PETC02, and the less the measured PETC02 reflects the actual PACO 2 or PaCCE.
[0076] Discussed herein are techniques to directly measure the fractional alveolar partial pressure of CO 2 (FACO 2 ) by reducing or eliminating the dilution effect of the alveolar dead space (VDalv) on the end tidal partial pressure of CO 2 (PETC02), thus making the end tidal partial pressure of CO 2 (PETC02) about equal to FACO 2 . The present techniques apply this determined FACO 2 proxy, as in Equation 1 below, to calculate the ratio of the alveolar dead space to tidal volume (VDalv / VT) and, further, when tidal volume (VT) is measured or otherwise known, to calculate the alveolar dead space (VDalv).
[0077] Considering the alveolar partial pressure of CO 2 (PACO 2 ), which is taken to be equal to the arterial partial pressure of CO 2 (PaCCE) as discussed above, then the amount of alveolar dead space (VDalv) that would be required to produce the measured end tidal partial pressure of CO 2 (PETCCE) can be computed as:
[0078] (VT - VDanat - VDalv) x FACO 2 = VT x FECCE
[0079] or by dividing both sides by VT and FACO 2 and simplifying:
[0080] 1 - Vdalv / (Vi - VDanat) = FECCE / FACO 2
[0081] VDalv / (Vi - VDanat) = 1 - FECCE / FACO 2 (Eq. 1),
[0082] with the assumptions that all of the CO 2 exhaled comes from the perfused alveoli and that the alveolar dead space (VDalv) contributes no CO 2 .
[0083] As a simplification, this can be estimated for single breaths where the fractional end tidal partial pressure of CO 2 (FETCCE) is determined only by the fractional alveolar partial pressure of CO 2 (FACO 2 ) and the alveolar dead space (VDalv). Use of sequential gas delivery reduces or eliminates the anatomical dead space (VDanat) from the calculation, so that looking only at the volume of gas entering the alveoli (V A ) where:
[0084] Vi - VDalv = V A = G 1 / f B [0085] and allowing the substitution of FETC02 for FECO2, thus it can be said that:
[0086] (VT - VDalv) x FACO2 = VT X FETC02 [0087] 1 - VDalv / ( VT - VDanat) = FETC0 / FACO2
[0088] VDalv / V A = 1 - F ET C0 / FACO2 (Eq. 2).
[0089] In the above, FETCCE and VT may be measured, leaving three unknowns: VDanat,
FACO2, and VDalv. VDanat may be eliminated with sequential gas delivery, as will be discussed below. FACO2 and VDalv are related to each other and represent only one degree of freedom. Hence, knowing one determines the other. PACO2 can be estimated from the Phase III (see above and FIGs. 1A and IB) or from the PaCCE. The techniques discussed herein provide for measuring FETCCE and PACO2 and thus, via Equation 2, determining VDalv using direct measurement.
[0090] FIG. 3 shows a device 100 to provide sequential gas delivery to a subject 130 and determine the subject’s alveolar dead space (VDalv). The device 100 includes gas supplies 102, a gas blender 104, a mask 108, a processor 110, memory 112, and a user interface device 114. The device 100 may be configured to control end-tidal PCO2 and end-tidal PO2 by generating predictions of gas flows to actuate target end-tidal values. The device 100 may be an RespirAct™ device, made by Thornhill Medical™ of Toronto, Canada, specifically configured to implement the techniques discussed herein. For further information regarding sequential gas delivery, US Pat. 8,844,528, US Pub. 2018/0043117, and US Pat. 10,850,052, which are incorporated herein by reference, may be consulted.
[0091] The gas supplies 102 may provide carbon dioxide, oxygen, nitrogen, and air, for example, at controllable rates, as defined by the processor 110. The following gas mixtures may be used. Gas A: 10% O2, 90% N2; Gas B: 10% O2, 90% CO2; Gas C: 100% O2; and a calibration gas:
10% O2, 9% CO2, 81% N2.
[0092] The gas blender 104 is connected to the gas supplies 102, receives gasses from the gas supplies 102, and blends received gasses as controlled by the processor 110 to obtain a gas mixture, such as a first gas (Gl) and a second gas (G2) for sequential gas delivery. [0093] The second gas (G2) is a neutral gas in the sense that it has about the same PCO2 as the gas exhaled by the subject 130, which includes about 4% to 5% CO2. In some examples, the second gas (G2) may include gas actually exhaled by the subject 130. The first gas (Gl) has a composition that meets the respiratory needs of the subject and has a lower PCO2 than that of the second gas (G2). For example, the first gas (Gl) may be air (which typically has about 0.04% CO2), may consist of 21% oxygen and 79% nitrogen, or may be a gas of similar composition, preferably without any appreciable CO2.
[0094] The processor 110 may control the blender 104, such as by electronic valves, to deliver the gas mixture in a controlled manner.
[0095] The mask 108 is connected to the gas blender 104 and delivers gas to the subject 130. A valve arrangement 106 may be provided to the device 100 to limit the subject’s inhalation to gas provided by the blender 104 and limit exhalation to the room. An example valve arrangement 106 includes an inspiratory one-way valve from the blender 104 to the mask 108, a branch between the inspiratory one-way valve and the mask 108, and an expiratory one-way valve at the branch. Hence, the subject 130 inhales gas from the blender 104 and exhales gas to the room.
[0096] The gas supplies 102, gas blender 104, and mask 108 may be physically connectable by conduits, such as tubing, to convey gas. Any number of sensors 132 may be positioned at the gas blender 104, mask 108, and/or conduits to sense gas flow rate, pressure, temperature, and/or similar properties and provide this information to the processor 110. Gas properties may be sensed at any suitable location, so as to measure the properties of gas inhaled and/or exhaled by the subject 130.
[0097] The processor 110 may include a central processing unit (CPU), a microcontroller, a microprocessor, a processing core, a field-programmable gate array (FPGA), an application- specific integrated circuit (ASIC), or a similar device capable of executing instructions. The processor may be connected to and cooperate with the memory 112 that stores instructions and data.
[0098] The memory 112 includes a non-transitory machine-readable medium, such as an electronic, magnetic, optical, or other physical storage device that encodes the instructions. The medium may include, for example, random access memory (RAM), read-only memory (ROM), electrically erasable programmable read-only memory (EEPROM), flash memory, a storage drive, an optical device, or similar.
[0099] The user interface device 114 may include a display device, touchscreen, keyboard, buttons, and/or similar to allow for operator input/output.
[0100] Instructions 120 may be provided to carry out the functionality and methods described herein. The instructions 120 may be directly executed, such as a binary file, and/or may include interpretable code, bytecode, source code, or similar instructions that may undergo additional processing to be executed.
[0101] The instruction 120 perform sequential gas delivery by controlling the device 100 to deliver a first volume of a first gas (Gl) to the subject 130 over a first portion of an inspiration by the subject 130. The first volume is selected to be less than or equal to an estimated or expected alveolar volume (V A ) of the subject 130 when the subject is breathing normally. The first gas (Gl) has a PCO2 that is less than the PCO2 in the gas exhaled by the subject 130 and preferably no significant amount of CO2. The instructions 120 deliver a second volume of a second, neutral gas (G2) to the subject 130 over a second portion of the inspiration. The second gas is a neutral gas that has a PCO2 corresponding to the PCO2 in the exhaled gas and preferably the same amount of CO2 as present in the previously exhaled breath. The second gas (G2) is unlimited in the sense that during normal or deep breathing, the end of the inspiration will contain as much second gas (G2) as needed.
[0102] The instructions 120 measure a PCO2 at the end of an exhalation by the subject 130 occurring after delivery of the first and second gases (Gl, G2), that is the PETC02, while the subject breathes.
[0103] The instructions 120 may measure the subject’s P ET C0 2 during spontaneous normal breathing and deep breathing over a plurality of respiratory cycles, so as to allow measurements to stabilize and to allow for a mean to be computed.
[0104] The instructions 120 apply Equation 2 or equivalent to compute the alveolar dead space (VDalv) using the normal breathing P ET C0 2 and the subject’s PaC0 2 as the PACO2. [0105] Instead of invasively measuring the subject’s PaCCh, the subject’s PaCCh or PACO2 can be measured by having the subject breathe deeply, with the instructions 120 measuring P ET C02 at exhalation when the subject is breathing deeply. The deep breathing PETC02, as will be explained below, may then be taken as the PaCC or PACO2 (or the fractional equivalents). This is possible because, in the dead space alveoli, the larger the breath the closer the PCO2 approaches the equilibrated value. Hence, with each deep breath, the residual PCO2 in the dead space alveoli approach the equilibrated value. As the dead space PCO2 approaches the equilibrated value, the P ET C0 2 approaches the equilibrated value, that is, the P A C0 2 . The instructions 120 then take the deep breathing P ET C0 2 to be the PaCC or, more specifically, the PACO2 term in Equation 2.
[0106] Hence, the instructions 120 facilitate the computation of subject’s alveolar dead space (VDalv) based on a ratio of PETCCE during normal breathing to PETCCE during deep breathing. The effect of VDalv on FETCCE may be reduced or eliminated, so as to make FETCCE equal to FACO2.
[0107] The instructions 120 may further output the determined alveolar dead space (VDalv), or a representation thereof, at the user interface device 114. Further, the instructions 120 may cause the user interface device 114 to prompt the operator of the device 100 to operate the device 100 and instruct the subject 130, as discussed herein.
[0108] FIG. 4A shows an example method 200 of determining alveolar dead space. The method 200 may be implemented by instructions 120.
[0109] At block 202, the subject breathes normally. Sequential gas delivery may be used, as discussed above. The first gas (Gl) is delivered at a volume less than or equal to an estimated or expected alveolar volume VA of the subject. The neutral gas (G2), if not rebreathed gas, may have its PCO2 adjusted continually to match exhaled gas. During breathing, at block 204, the subject’s P ET C0 2 is measured. This continues for a time, via block 206, such as 20 seconds, 30 seconds, 1 minute, 2 minutes, or longer.
[0110] At block 208, the subject breathes deeply with sequential gas delivery. The first gas (Gl) is delivered at the same volume in block 202. During deep breathing, at block 210, the subject’s P ET C0 2 is measured. This continues for a time, via block 212, such as 20 seconds, 30 seconds, 1 minute, 2 minutes, or longer. The time may be governed by the slope or change in the curve of the measured P ET C0 2 (see FIG. 7), such that blocks 208 and 210 are performed until the P ET C0 2 stops its increasing trend and levels out.
[0111] At block 214, the alveolar dead space (VDalv) is computed using the ratio of the PETC02 measured from blocks 204 and 210, that is, by applying Equation 2. VDalv may be outputted as a ratio to VA or as an absolute value provided that VA is determined.
[0112] Further explanation of the above is provided with references to FIGs. 5A, 5B, and 6, which show a two-region alveolar model with one alveolar region perfused (at left) and one not (at right). In these figures, the functional residual capacity is show at 1, the functional residual capacity in dead space alveoli plus the equilibrated gas from the previous breath inhaled from the anatomical dead space is show at la, the part of VT entering the alveolus is shown at 2, mixed venous blood with PvC0 2 is shown at 3, and PCO2 in blood equilibrated with alveolar gas 1, 2 is shown at 3a.
[0113] With reference to FIG. 5 A, during normal/spontaneous breathing without sequential gas delivery, inspiration occurs at A-l to draw in fresh gas 2, 2a into the respective perfused alveolar region and non-perfused alveolar region, which respectively contain residual gas 1, 1a. Equilibration of CO2 and O2 between the gas in the alveoli and the pulmonary capillaries, at the perfused alveolar region, occurs at A-2. There is no equilibration in alveolar dead space. Exhalation at A-3 provides a mix of equilibrated gas 1, 2 and dead space gas la, 2a.
[0114] With reference to FIG. 5B, during sequential gas delivery with normal/spontaneous breathing, during inspiration at B-l a first gas (Gl) is distributed to both perfused and non- perfused (dead space) alveoli (2, 2a) and the latter part of inspiration includes second gas (G2) with PCO2 equal to equilibrated gas. The second gas (G2) fills the anatomical dead space. It does not matter if the second gas (G2) enters the gas exchange alveoli (see FIG. 6), so it is depicted as ending in the anatomical dead space. During gas exchange at B-2, the fresh gas or air 2 inhaled into the alveoli equilibrate with blood in alveolar capillaries. At exhalation B-3, this equilibrated gas mixes with alveolar dead space gas and the resulting PETC02 is substantially the same as normal breathing (see also FIG. 7). [0115] With sequential gas delivery at spontaneous respiration and normal VT, VT is divided into a first gas (Gl) which provides gas to all the alveoli (VA) followed by a second gas (G2) which has PCO2 and optionally PO2 equal to equilibrated gas. G2 fills only the VDanat, as shown in FIG. 5B at B-l. If all of the alveoli are capable of gas exchange, Gl is equal to the alveolar ventilation (VA) as long as VT > VA + VDanat. To the extent that there is VDalv in the VA, during exhalation, the proportion of gas from perfused alveoli and VDalv is the same as with normal breathing, as shown in FIG. 5B at A-3 and B-3, so that P ET C0 2 is also the same, as shown in FIG. 7.
[0116] With reference to FIG. 6, during sequential gas delivery with deep breathing, inspiration at C-l includes inspiration of first gas (Gl). The alveolar gas enters the perfused alveoli 2 and the dead space alveoli 2a. The subject takes a bigger breath at C-2 and draws into the perfused alveoli 4 and non-perfused alveoli 4a more equilibrated gas (G2). In the perfused alveoli, the inhaled fresh gas equilibrates at C-3 with the mixed venous gas. Because the volume of fresh gas is the same as at rest or regular/spontaneous (non-deep) breathing, the equilibrium PCO2 is the same as at rest, i.e., PACO2. In the dead space alveoli, the inhaled fresh gas (Gl) is diluted by equilibrated gas (G2), and PCO2 rises towards that in equilibrated gas (G2). Regardless of the size of the breath, the perfused alveolar PCO2 is unchanged. However, in the dead space alveoli, the bigger the breath, the closer the PCO2 approaches the equilibrated value. With each breath, the residual PCO2 in the dead space alveoli approach the equilibrated value. As the dead space PCO2 approaches the equilibrated value at C-4, the P ET C0 2 approaches the equilibrated value, that is, PACO2.
[0117] In other words, the subject takes a deep breath at C-2, and the VA, both the part with perfused alveoli and that with dead space alveoli, now contains its FRC + Gl + an expanded volume of G2. This gas enters the perfused alveoli 4 at C-2 and the dead space 4a. At equilibration at C-3, the perfused alveoli equilibrate to PACO2 as in normal breathing, but the PCO2 in the VDalv now rises from about 0 towards PETC02. Thus, on exhalation, PETC02 approaches PACO2.
[0118] Deep breaths with sequential gas delivery send equilibrated gas to the VDalv and dilute out first gas (Gl), and wash out the previous gas, such that the PCO2 in the VDalv approaches the PACO2. Thus, PETC02 approaches PACO2. This PACO2 is used in Equation 2 to calculate VDalv / V A .
[0119] FIG. 7 shows a VDalv / V A test plotted as P ET CCE VS. time. At left, initial normal/free breathing occurs with breath-to-breath variation. This is followed by sequential gas delivery at a normal breathing rate with less variation, which is followed by sequential gas delivery with deep breaths. Each dot is a P ET CCE measurement. It took about 30 seconds to wash out the VDalv and come to a new equilibrium P ET CCE.
[0120] The techniques described above may be used to assess a medical condition such as heart failure, congestive heart failure, adult respiratory distress syndrome, lung function after lung transplant, lung function after transplant, sepsis, trauma, or pulmonary and systemic disease. That is, a directly measurable alveolar dead space may be useful is assessing such conditions. Moreover, measuring alveolar dead space may be used as a marker for the severity and duration of congestive heart failure.
[0121] Example
[0122] An example of measuring VDalv using the techniques described herein will now be discussed.
[0123] 1. A subject is in a resting steady state of breathing and oxygen consumption;
[0124] 2. The subject breathes via a tight-fitting mask or mouthpiece, endotracheal tube, or laryngeal mask such that:
[0125] a. The volume and concentrations of CO2 in all inspired gases are controlled and measured,
[0126] b. PCO2 is measured continuously on exhalation,
[0127] c. P ET CCE is measured breath-by-breath, and [0128] d. Tidal volumes are measured breath-by-breath;
[0129] 3. VDanat is calculated as 2.2 ml / kg body weight + 1 ml x age or with a similar method; [0130] 4. Sequential gas delivery (SGD) is performed by:
[0131] a. Measuring the breathing frequency (f B ) and tidal volumes (VT) in a steady state, [0132] b. Calculating VDalv by one of the following:
[0133] i. Calculate the approximate anatomical dead space (VDanat) from tables,
[0134] ii. Assume VDanat to be 2.2 ml/kg + 1 ml x age,
[0135] iii. Measure the VDanat by progressive reduction of the first gas (Gl) below VE and observe inflection to increase in PETC02. VDanat = difference in flow between VE and at flow at the upward inflection, divided by breathing frequency (f B ),
[0136] iv. Set first gas (Gl) flow is equal to VT - VDanat x f B ,
[0137] v. Set PCO2 of second gas (G2) to P ET C0 2 of previous breath,
[0138] 5. During SGD there is no change in P ET C0 2 from free breathing to SGD (see FIG. 7);
[0139] 6. Subject begins to hyperventilate taking deep breaths. The time constant of washout of
VDalv will be FRC / (VT X f B ). For example, assuming FRC of 4 F, breaths of 2 F, breathing frequency of 20 / min, and a time constant of washout of the lung of 3 seconds, therefore at 9 second there will be 95% washout of VDalv with the second gas (G2); and
[0140] 7. Measure P ET C0 2 during deep breathing and take the P ET C0 2 as PACO2. To the extent that the PCO2 in the alveolar dead space approaches the PETC02, the PETC02 will rise and asymptote at the PACO2, as shown in FIG. 7; and
[0141] 8. Compute VDalv using Equation 2.
[0142] In view of the above, it should be apparent that a convenient, quick, non-invasive, and accurate measurement of alveolar dead space (VDalv) may be realized using the techniques discussed herein. Further, since all inputs (namely VT, FETC02 during normal breathing, and FACO2 as F ET C0 2 during deep breathing) to compute VDalv are measurable or directly computable from measurements, the present disclosure provides a gold standard measure that depends only on the precision of the measurements and not on approximations or unfounded assumptions.
[0143] It should be recognized that features and aspects of the various examples provided above can be combined into further examples that also fall within the scope of the present disclosure. In addition, the figures are not to scale and may have size and shape exaggerated for illustrative purposes.