getting high john p. hunt lsu new orleans department of surgery
TRANSCRIPT
Which person could have this blood gas?
7.65/14/35/15/71%1) Scuba diver on his third 100 ft dive of the
day
2) A marathon runner during a race
3) A mountain climber at 22,000 ft
4) A COPD patient in respiratory distress
American Board of Surgery, written exam, 1995
Oxygen Delivery –From Start to Finish: Changes at Altitude
as a Model
John P. Hunt
LSU New Orleans
Department of Surgery
Objectives• Historical Perspectives
• Environmental and physiological changes
• Symptoms
• Effects on DO2
• Prevention
• Therapy
Historical Perspectives• “Men’s bodies become
feverish, they lose color and are attacked with headache and vomiting; the asses and cattle being in the same condition”
Qian Han Shu, 30 BC
Historical Perspectives
• “I was quite out of breathe from the rarity of the air”
DeSaussure 1787
• “I feel funny and I don’t know why, excuse me while I kiss the sky”
Hendrix 1969
Historical Perspectives• “After we huddle over our ice axes,
mouths agape, struggling for sufficient breath… I feel I no longer belong to myself and my eyesight. I am nothing more then a single narrow gasping lung”
Messner 1978
Incidence
• 67% of mountaineers ascending Mount Rainier (14,405 ft)
• 53 % of trekkers in the Himalayas (13,900 ft)
• 12% of Coloradoskiers (8,000 ft)
High Altitude Cerebral Edema (HACE)
• Less than 1% of all Mountain sickness
• Always above 12,000 Ft• Symptoms: Severe headache,
Ataxia, Loss of co-ordination, Diplopia, Confusion, Hallucinations, Death
Acute Mountain Sickness (AMS)
• Usually above 10,000 Ft
• Onset is 4-6 hours after exposure & Duration 3 Days
• Symptoms: Headache, Insomnia, Irritability, Fatique, Nausea/vomiting
High Altitude Pulmonary Edema (HAPE)
• Rarely below 8,000 Ft• Onset is 1-3 days after
exposure• Symptoms: Dyspnea at rest,
Pink frothy sputum, Rales, Cyanosis, mild temperature
Temperature at Altitude
-60
-40
-20
0
20
40
60
80
0 10,000 20,000 30,000
Altitude (ft)
Tem
per
atu
re (F
)
Oxygen Availability at Altitude
50
70
90
110
130
150
170
0 3,000 6,000Par
tial
Pre
ssu
re o
f O
2 (m
m t
orr)
Altitude (meters)
Oxygen Delivery may be calculated as a function of?
1) C.O., O2 saturation, mvO2 saturation
2) C.O., mvO2 extraction, mvO2 saturation
3) C.O., mvO2 saturation, Hgb
4) C.O., Hgb, O2 saturation
5) Difference between mvO2 saturation O2 saturation and C.O.
Acute Hypoxia Produces?
1) Increased pulmonary vascular resistance
2) Increased pulmonary blood flow
3) Increased total blood volume
4) Decreased epinephrine
5) Increased splanchnic perfusion
0
50
100
150
Inspired Alveolar Arterial Venous Tissue
Sea Level
Altitude
Level
Comparative Oxygen TensionP
arti
al P
ress
ure
O2
Ventilation
How does Ventilation Improve Oxygenation?
• Classic Ventilator Management dictates
-M.V. – PCO2
-FiO2 – PO2
0
50
100
150
Inspired Alveolar Arterial Venous Tissue
Sea Level
Altitude
Level
Comparative Oxygen TensionP
arti
al P
ress
ure
O2
V/Q Mismatch
0
10
20
30
40
50
60
70
80
90
0 5,000 6,000 7,500 9,000
Diffusion
V/Q Mismatch
Altitude (M)
V/Q Mismatch and Diffusion%
Tot
al A
-a P
O2
Wagner PD et al J Appl Physiol 1987;63:2348
3 days following operation for a perforated ulcer a 68 y.o man requires intubation.
Initial ABG on 100% shows 7.32/72/36. To improve oxygenation the ventilator should
be adjusted to?
1) Increase minute ventilation
2) Decrease minute ventilation
3) Increase functional residual capacity
4) Increase compliance
5) Decrease the I:E ratio
The primary mechanism by which PEEP improves oxygenation is?
1) Decreased air-flow resistance2) Increased functional residual capacity3) Increased forced vital capacity4) Decreased interstitial lung water5) Decreased ratio of dead space to total
volume
0
50
100
150
Inspired Alveolar Arterial Venous Tissue
Sea Level
Altitude
Level
Comparative Oxygen TensionP
arti
al P
ress
ure
O2
Circulation & Extraction
Hemoglobin
• 33% Increase in Hgb
• Secondary to significant increases in erythropoetin
• Chronic exposure typically yields Hct in the 60 range
Starling Mechanism• Dehydration and
subsequent decrease in preload is the mountaineers worst enemy
• 80% of carried fuel is used to make water
0
5
10
15
Car
dia
c O
utp
ut
EDV
Starlings Law states that cardiac contractility increases when?
1) SVR Increases
2) SV Increases
3) LVSW Decreases
4) EDV Increases
5) SV Increases and SVR Increases
Hemoglobin-Oxygen Dissociation
• Shifting the curve to the right decreases the affinity of hemoglobin for oxygen inducing off-loading
-Increased temp
-Decreased pH
-Increased CO2
-Increased 2-3 DPG
01020304050
60708090
100
0 40 60 80 100
PaO2
O2
Sat
A Shift in the Oxygen-Hemoglobin-Dissociation curve to
the right is characteristic of?1) Hyperventilation2) Increased carboxy-hemoglobin3) Decreased affinity of hemoglobin for
oxygen
4) Decreased A-V O2 difference5) May be caused by hypothermia
Extraction Ratio
• VO2/DO2
• VO2 = Q x (Ca02 – Cv02)
= Q x 1.34 x Hgb (Sa02 – MV02)
• Mountaineers have a maximized extraction ratio
At rest MvO2 Saturation?
1) Normally ranges between .48-.55
2) Increases as O2 consumption increases3) Increases as Hgb decreases4) Increases as Cardiac Output increases5) Decreases as Arterial oxygen saturation
increases
Nifedipine For HAPE• 21 volunteers with
previous history of HAPE
• Ascended to 4559 M• Nifedipine vs Placebo• Pulmonary edema in 1 in
10 of treated group vs 7 of 11 in control group
• Reproduced by Oelz O. et al
0
10
20
30
40
50
60
PAPressure
A-agradient
PlaceoNifedipine
Bartsch P. et al NEJM 1996;325:1284
Acetazolamide For AMS• 64 healthy volunteers
ascending Mount Rainier• 93.6% of treatment group
and 75.8% of controls reached the summit
• 66.7% of controls and 17.2% of the treatment group developed AMS
• Reproduced by Grissom et al on Denali
0
5
10
15
20
25
MinuteVolume
Vitalcapacity
Placeo
Acetazolamide
Larson EB. et al JAMA 1982;248:329
Summary• Mountain Climbers optimize O2
delivery by-A four-fold increase in ventilation-Optimizing V/Q matching-Increasing Hgb via erythropoesis
-Optimizing the O2 Extraction Ratio
Summary• HACE, HAPE, AMS are different
forms of Altitude sickness• Judicious climbing practices and
medical prophylaxis are warranted
• Descent is the best therapy for altitude sickness