Isocapnic hyperpnea (IH): fast-filtering foreign gases
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1 Isocapnic hyperpnea (IH): fast-filtering foreign gases Joseph A. Fisher M.D. FRCP(C) Professor, Faculty of Medicine University of Toronto and Chief Scientist, Thornhill Research Inc.
2 Aims: isocapnic hyperpnea (IH) What is it? What can it be used for? How does it work? Why does it work?
3 Background Uptake and of
4 uptake: CBF Tissue 1 Tissue 2 Tissue n
5 uptake: CBF Tissue 1 á V E Tissue 2 Tissue n
6 uptake: CBF á V E á [lung] Tissue 1 Tissue 2 Tissue n
7 uptake: lung and blood: via V E Brain: via CBF CBF á [blood] [An] gradient á [lung] Tissue 1 á V E Tissue 2 Tissue n
8 clearance: á V E Tissue 1 V E Tissue 2 Tissue n
9 clearance: á V E [lung] Tissue 1 V E Tissue 2 Tissue n
10 clearance: á V E [lung] [blood] [An] gradient á [An] gradient form brain Tissue 1 V E Tissue 2 Tissue n
11 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient Tissue 1 V E Tissue n Tissue 2
12 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient Tissue 1 V E Tissue n Tissue 2
13 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient Tissue 1 V E Tissue n Tissue 2
14 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient Tissue 1 V E Tissue n Tissue 2
15 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient Tissue 1 V E Tissue n Tissue 2
16 clearance: á V E [lung] PaCO 2 [blood] á [An] gradient form brain CBF [An] gradient
17 clearance:! V E [lung] PaCO 2 [blood]! [An] gradient form brain CBF [An] gradient
18 clearance:! V E [lung] PaCO 2 [blood]! [An] gradient form brain CBF [An] gradient
19 clearance:! V E [lung] PaCO 2 [blood]! [An] gradient form brain CBF [An] gradient First issue: maintain isocapnia
20 Rebreathing series deadspace rebreathes An as well as CO 2 PaCO 2 not isocapnic 40 V E
21 Needed: A separate effect on anaesthe'c and on CO 2
22 Principle : Exhaled gas has equilibrated with the alveoli. **Does not contribute to gas exchange.
23 gas delivery Gas 1: non O rebreathing 2 demand regulator CO 2 is like in exhaled gas Gas 2 5% CO 2 Bal O 2 Gas bag (reservoir)
24 gas delivery Gas 1: O 2 Demand regulator Gas 2 5% CO 2 Gas bag (reservoir) Bal O 2 FRC FRC Gas 1 FRC A B Inspira@on C
25 gas delivery Gas 1: non O rebreathing 2 Gas bag (reservoir) Demand regulator Gas 2 5% CO 2 Bal O 2 Gas 1 = FRC FRC FRC FRC A B Inspira@on C D F
26 gas delivery Gas 1: non O rebreathing 2 Gas bag (reservoir) Demand regulator Gas 2 5% CO 2 Bal O 2 FRC FRC A B Inspira@on Gas 1 FRC C = FRC D FGF = FRC E = FGF FRC FRC F
27 Principle : 5% CO 2 **Does not contribute to gas exchange. total ven@la@on = FGF FRC FRC no CO 2 exchange CO 2 exchange
28 A PCO 2 (mmhg) 40 0 end-tidal PCO 2 VE (L/min) (min) Fisher et al. Exp Phys. 96(12);
29 A B PCO 2 (mmhg) 40 0 end-tidal PCO 2 End-tidal PCO 2 inspired PCO 2 VE (L/min) (min) 3 6 (min) Fisher et al. Exp Phys. 96(12);
30 Gas bag (reservoir) demand valve Gas 1: non O 2 rebreathing Demand regulator Gas 2 5% CO 2 Bal O 2 Gas bag (reservoir)
31 demand valve O 2 5% CO 2 bal O 2 CO 2 O 2
32 IH in the clearance of * Or any other hydrocarbons
33 Principle : total ven@la@on *An exchange = FGF FRC FRC no CO 2 exchange CO 2 exchange
34 Vesely et al. BJA (2003) 91(6):
35 Vesely et al. BJA (2003) 91(6):
36 IH with sevoflurane Katznelson A&A (106):
37 Katznelson A&A (106):
38 Effect doesn t last into PACU Katznelson A&A (106):
39 Isoflurane ( λ 1.4) $$$$ Sevoflurane (λ 0.6) $$$$ dopamine 1 receptor anatagonist 30% shorter wake- up
40 Isoflurane ( λ 1.4) $$$$ Sevoflurane (λ 0.6) $$$$ dopamine 1 receptor anatagonist 30% shorter wake- up $ IH Clearance VA (L/min) sevoflurane isoflurane
41 Isoflurane ( λ 1.4) $$$$ Sevoflurane (λ 0.6) $$$$ dopamine 1 receptor anatagonist 30% shorter wake- up $ IH Clearance VA (L/min) sevoflurane isoflurane
42 IH and the clearance of highly soluble hydrocarbons: CO
43 Rx of CO poisoning Air + COHb CO + O 2 Hb O 2 + COHb CO + O 2 Hb HBO 2 + COHb CO + O 2 Hb
44 Can IH to reduce COHb? O 2 + COHb CO + O 2 Hb IH does nothing for PO 2 IH does nothing to Hb affinity for CO: keeps CO on rbc IH can reduce PCO in alveoli: But PCO in blood is low. Is this puny gradient is worth it? Won t work?
45 Can IH reduce COHb? Maybe! The large store of CO in the blood... maintains PCO gradient... transfers CO equilibrium... so total CO elim α VA comes out of fast compartments: lung, blood so just may have rapid drop in [COHb] So, how important is this effect, say, relazve ot HBO 2?
46 COHb (% saturation) CO poisoning Room air 100% O O 2 + I H Time (min) Fisher et al. Am.J.Crit.Care Med :
47 70 COHb (% saturation) CO poisoning Room air Hyperbaric O 2 Treatment 1 Hyperbaric O 2 Treatment Time (min) Fisher et al. Am.J.Crit.Care Med :
48 CO poisoning Room air COHb (% saturation) CO poisoning Room air 100% O O 2 + I H Hyperbaric O 2 Treatment 1 Hyperbaric O 2 Treatment Time (min)
49 t1/2 reduction in [COHb] Air 100% O 2 O 2 + IH HBO 2 Fisher Am J Resp Crit Care Med.1999;159:
50 Minute ventilation vs t 1/2 in humans Small increase in VE 120 t 1/2 [COHb] (min) x + Large reduczon in t1/2 x Minute ventilation (ml min -1 kg -1 ) Takeuchi et al. Am J Resp Crit Care Med. 161,
51 Aims: isocapnic hyperpnea (IH) What is it? What can it be used for? How does it work? Why does it work?
52 Take home message : IH: total ven@la@on *An exchange *CO exchange = FGF FRC FRC no CO 2 exchange CO 2 exchange * Or any other vola@le hydrocarbons
53 Aims: isocapnic hyperpnea (IH) What is it? What can it be used for? How does it work? Why does it work? Is it safe? How would I implement it at my place?
54 demand valve O 2 5% CO 2 bal O 2 CO 2 O 2
55
56
57 ANEclear, QED Gopalakrishnan A&A (104):815-21
58 IH ANEclear simple ++/ /++++ Control PCO 2 independent of VE Risk of â PO 2 N Y Risk of á PCO 2 N Y Airway R- spont vent unchanged á Minimum VT No ~ 0.5 L cost ++/ /++++ Y N
59 Gopalakrishnan A&A (104):815-21
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