Is providing elective ventilation in the best interests of potential donors?

In this paper, we examine the lawfulness of a proposal to provide elective ventilation to incompetent patients who are potential organ donors. Under the current legal framework, this depends on whether the best interests test could be satisfied. It might be argued that, because the Mental Capacity Act 2005 (UK) (and the common law) makes it clear that the best interests test is not confined to the patient's clinical interests, but extends to include the individual's own values, wishes and beliefs, the proposal will be in the patient's best interests. We reject this claim. We argue that, as things currently stand, the proposal could not lawfully be justified as a blanket proposition by reference to the best interests test. Accordingly, a modification of the law would be necessary to render the proposal lawful. We conclude with a suggestion about how that could be achieved.

Ventilation distribution in rats : Part I - The effect of gas composition as measured with electrical impedance tomography

The measurement of ventilation distribution is currently performed using inhaled tracer gases for multiple breath inhalation studies or imaging techniques to quantify spatial gas distribution. Most tracer gases used for these studies have properties different from that of air. The effect of gas density on regional ventilation distribution has not been studied. This study aimed to measure the effect of gas density on regional ventilation distribution. Methods Ventilation distribution was measured in seven rats using electrical impedance tomography (EIT) in supine, prone, left and right lateral positions while being mechanically ventilated with either air, heliox (30% oxygen, 70% helium) or sulfur hexafluoride (20% SF6, 20% oxygen, 60% air). The effect of gas density on regional ventilation distribution was assessed. Results Gas density did not impact on regional ventilation distribution. The non-dependent lung was better ventilated in all four body positions. Gas density had no further impact on regional filling characteristics. The filling characteristics followed an anatomical pattern with the anterior and left lung showing a greater impedance change during the initial phase of the inspiration. Conclusion It was shown that gas density did not impact on convection dependent ventilation distribution in rats measured with EIT.

Ventilation distribution in rats : part 2 – a comparison of electrical impedance tomography and hyperpolarised helium magnetic resonance imaging

Background: Hyperpolarised helium MRI (He3 MRI) is a new technique that enables imaging of the air distribution within the lungs. This allows accurate determination of the ventilation distribution in vivo. The technique has the disadvantages of requiring an expensive helium isotope, complex apparatus and moving the patient to a compatible MRI scanner. Electrical impedance tomography (EIT) a non-invasive bedside technique that allows constant monitoring of lung impedance, which is dependent on changes in air space capacity in the lung. We have used He3MRI measurements of ventilation distribution as the gold standard for assessment of EIT. Methods: Seven rats were ventilated in supine, prone, left and right lateral position with 70% helium/30% oxygen for EIT measurements and pure helium for He3 MRI. The same ventilator and settings were used for both measurements. Image dimensions, geometric centre and global in homogeneity index were calculated. Results: EIT images were smaller and of lower resolution and contained less anatomical detail than those from He3 MRI. However, both methods could measure positional induced changes in lung ventilation, as assessed by the geometric centre. The global in homogeneity index were comparable between the techniques. Conclusion: EIT is a suitable technique for monitoring ventilation distribution and inhomgeneity as assessed by comparison with He3 MRI.

Influence of ventilation and filtration on indoor particle concentrations in urban office buildings

This study aimed to quantify the efficiency of deep bag and electrostatic filters, and assess the influence of ventilation systems using these filters on indoor fine (<2.5 µm) and ultrafine particle concentrations in commercial office buildings. Measurements and modelling were conducted for different indoor and outdoor particle source scenarios at three office buildings in Brisbane, Australia. Overall, the in-situ efficiency, measured for particles in size ranges 6 to 3000 nm, of the deep bag filters ranged from 26.3 to 46.9% for the three buildings, while the in-situ efficiency of the electrostatic filter in one building was 60.2%. The highest PN and PM2.5 concentrations in one of the office buildings (up to 131% and 31% higher than the other two buildings, respectively) were due to the proximity of the building’s HVAC air intakes to a nearby bus-only roadway, as well as its higher outdoor ventilation rate. The lowest PN and PM2.5 concentrations (up to 57% and 24% lower than the other two buildings, respectively) were measured in a building that utilised both outdoor and mixing air filters in its HVAC system. Indoor PN concentrations were strongly influenced by outdoor levels and were significantly higher during rush-hours (up to 41%) and nucleation events (up to 57%), compared to working-hours, for all three buildings. This is the first time that the influence of new particle formation on indoor particle concentrations has been identified and quantified. A dynamic model for indoor PN concentration, which performed adequately in this study also revealed that using mixing/outdoor air filters can significantly reduce indoor particle concentration in buildings where indoor air was strongly influenced by outdoor particle levels. This work provides a scientific basis for the selection and location of appropriate filters and outdoor air intakes, during the design of new, or upgrade of existing, building HVAC systems. The results also serve to provide a better understanding of indoor particle dynamics and behaviours under different ventilation and particle source scenarios, and highlight effective methods to reduce exposure to particles in commercial office buildings.

Respiratory monitoring practices during procedural sedation and analgesia in the cardiac catheterisation laboratory could be improved by using capnography to assess ventilation

Background: Procedural sedation and analgesia (PSA) administered by nurses in the cardiac catheterisation laboratory (CCL) is unlikely to yield serious complications. However, the safety of this practice is dependent on timely identification and treatment of depressed respiratory function. Aim: Describe respiratory monitoring in the CCL. Methods: Retrospective medical record audit of adult patients who underwent a procedure in the CCLs of one private hospital in Brisbane during May and June 2010. An electronic database was used to identify subjects and an audit tool ensured data collection was standardised. Results: Nurses administered PSA during 172/473 (37%) procedures including coronary angiographies, percutaneous coronary interventions, electrophysiology studies, radiofrequency ablations, cardiac pacemakers, implantable cardioverter defibrillators, temporary pacing leads and peripheral vascular interventions. Oxygen saturations were recorded during 160/172 (23%) procedures, respiration rate was recorded during 17/172 (10%) procedures, use of oxygen supplementation was recorded during 40/172 (23%) procedures and 13/172 (7.5%; 95% CI=3.59–11.41%) patients experienced oxygen desaturation. Conclusion: Although oxygen saturation was routinely documented, nurses did not regularly record respiration observations. It is likely that surgical draping and the requirement to minimise radiation exposure interfered with nurses’ ability to observe respiration. Capnography could overcome these barriers to respiration assessment as its accurate measurement of exhaled carbon dioxide coupled with the easily interpretable waveform output it produces, which displays a breath-by-breath account of ventilation, enables identification of respiratory depression in real-time. Results of this audit emphasise the need to ascertain the clinical benefits associated with using capnography to assess ventilation during PSA in the CCL.

Natural ventilation heuristics in high-rise residential buildings : evaluation and prediction

Complex behaviour of air flow in the buildings makes it difficult to predict. Consequently, architects use common strategies for designing buildings with adequate natural ventilation. However, each climate needs specific strategies and there are not many heuristics for subtropical climate in literature. Furthermore, most of these common strategies are based on low-rise buildings and their performance for high-rise buildings might be different due to the increase of the wind speed with increase in the height. This study uses Computational Fluid Dynamics (CFD) to evaluate these rules of thumb for natural ventilation for multi-residential buildings in subtropical climate. Four design proposals for multi-residential towers with natural ventilation which were produced in intensive two days charrette were evaluated using CFD. The results show that all the buildings reach acceptable level of wind speed in living areas and poor amount of air flow in sleeping areas.

The time taken for the regional distribution of ventilation to stabilise: An investigation using electrical impedance tomography

Electrical impedance tomography is a novel technology capable of quantifying ventilation distribution in the lung in real time during various therapeutic manoeuvres. The technique requires changes to the patient’s position to place the electrical impedance tomography electrodes circumferentially around the thorax. The impact of these position changes on the time taken to stabilise the regional distribution of ventilation determined by electrical impedance tomography is unknown. This study aimed to determine the time taken for the regional distribution of ventilation determined by electrical impedance tomography to stabilise after changing position. Eight healthy, male volunteers were connected to electrical impedance tomography and a pneumotachometer. After 30 minutes stabilisation supine, participants were moved into 60 degrees Fowler’s position and then returned to supine. Thirty minutes was spent in each position. Concurrent readings of ventilation distribution and tidal volumes were taken every five minutes. A mixed regression model with a random intercept was used to compare the positions and changes over time. The anterior-posterior distribution stabilised after ten minutes in Fowler’s position and ten minutes after returning to supine. Left-right stabilisation was achieved after 15 minutes in Fowler’s position and supine. A minimum of 15 minutes of stabilisation should be allowed for spontaneously breathing individuals when assessing ventilation distribution. This time allows stabilisation to occur in the anterior-posterior direction as well as the left-right direction.

Investigation of the effect of balconies on natural ventilation of dwellings in high-rise residential buildings in subtropical climate

Balconies, as one of the main architectural features in subtropical climates, are assumed to enhance the ventilation performance of buildings by redirecting the wind. Although there are some studies on the effect of balconies on natural ventilation inside buildings, the majority have been conducted on single zone buildings with simple geometries. The purpose of this study is to explore the effect of balconies on the internal air flow pattern and ventilation performance of multi-storey residential buildings with internal partitions. To this end, a sample residential unit was selected for investigation and three different conditions tested, base case (no balcony), an open balcony and a semi-enclosed balcony. Computational Fluid Dynamics is used as an analysis method due to its accuracy and ability to provide detailed results. The cases are analysed in terms of average velocity, flow uniformity and number of Air Changes per Hour (ACH). The results suggest the introduction of a semi-enclosed balcony into high-rise dwellings improves the average velocity and flow uniformity. Integrating an open balcony results in reduction of the aforementioned parameters at 0° wind incidence.

Risk assessment for airborne infectious diseases between natural ventilation and split-system air conditioner in a university classroom

Indoor air quality is a critical factor in the classroom due to high people concentration in a unique space. Indoor air pollutant might increase the chance of both long and short-term health problems among students and staff, reduce the productivity of teachers and degrade the student’s learning environment and comfort. Adequate air distribution strategies may reduce risk of infection in classroom. So, the purpose of air distribution systems in a classroom is not only to maximize conditions for thermal comfort, but also to remove indoor contaminants. Natural ventilation has the potential to play a significant role in achieving improvements in IAQ. The present study compares the risk of airborne infection between Natural Ventilation (opening windows and doors) and a Split-System Air Conditioner in a university classroom. The Wells-Riley model was used to predict the risk of indoor airborne transmission of infectious diseases such as influenza, measles and tuberculosis. For each case, the air exchange rate was measured using a CO2 tracer gas technique. It was found that opening windows and doors provided an air exchange rate of 2.3 air changes/hour (ACH), while with the Split System it was 0.6 ACH. The risk of airborne infection ranged between 4.24 to 30.86 % when using the Natural Ventilation and between 8.99 to 43.19% when using the Split System. The difference of airborne infection risk between the Split System and the Natural Ventilation ranged from 47 to 56%. Opening windows and doors maximize Natural Ventilation so that the risk of airborne contagion is much lower than with Split System.

Nutrition during noninvasive ventilation: clinical determinants and key practical recommendations

Malnutrition and poor nutritional intake have been identified as key issues associated with poorer clinical outcomes in chronic obstructive pulmonary disease (COPD) patients. There is strong evidence showing nutritional support is effective in treating malnutrition in stable COPD, but there is only limited research regarding nutritional status in patients treated with noninvasive ventilation (NIV). The impact of NIV during acute exacerbations of respiratory disease on nutritional status requires further investigation.

Physiological and symptomatic responses to cycling and walking in intermittent claudication

To shed light on the potential efficacy of cycling as a testing modality in the treatment of intermittent claudication (IC), this study compared physiological and symptomatic responses to graded walking and cycling tests in claudicants. Sixteen subjects with peripheral arterial disease (resting ankle: brachial index (ABI) < 0.9) and IC completed a maximal graded treadmill walking (T) and cycle (C) test after three familiarization tests on each mode. During each test, symptoms, oxygen uptake (VO2), minute ventilation (VE), respiratory exchange ratio (RER) and heart rate (HR) were measured, and for 10 min after each test the brachial and ankle systolic pressures were recorded. All but one subject experienced calf pain as the primary limiting symptom during T; whereas the symptoms were more varied during C and included thigh pain, calf pain and dyspnoea. Although maximal exercise time was significantly longer on C than T (690 +/- 67 vs. 495 +/- 57 s), peak VO2, peak VE and peak heart rate during C and T were not different; whereas peak RER was higher during C. These responses during C and T were also positively correlated (P < 0.05) with each other, with the exception of RER. The postexercise systolic pressures were also not different between C and T. However, the peak decline in ankle pressures from resting values after C and T were not correlated with each other. These data demonstrate that cycling and walking induce a similar level of metabolic and cardiovascular strain, but that the primary limiting symptoms and haemodynamic response in an individual's extremity, measured after exercise, can differ substantially between these two modes.

Subtropical subdivisions : toward a lot-rating methodology for subtropical climates

What role can climatically appropriate subdivision design play in decreasing the use of energy required to cool premises by maximising access to natural ventilation? How can this design be achieved? The subdivision design stage is critical to urban and suburban sustainability outcomes, as significant changes after development are constrained by the configuration of the subdivision, and then by the construction of the dwellings. Existing Australian lot rating methodologies for energy efficiency, such as that by the Sustainable Energy Development Authority (SEDA), focus on reducing heating needs by increasing solar access, a key need in Australia’s temperate zone. A recent CRC CI project, Sustainable Subdivisions: Energy (Miller and Ambrose 2005) examined these guidelines to see if they could be adapted for use in subtropical South East Queensland (SEQ). Correlating the lot ratings with dwelling ratings, the project found that the SEDA guidelines would need to be modified for use to make allowance for natural ventilation. In SEQ, solar access for heating is less important than access to natural ventilation, and there is a need to reduce energy used to cool dwellings. In Queensland, the incidence of residential air-conditioning was predicted to reach 50 per cent by the end of 2005 (Mickel 2004). The CRC-CI, Sustainable Subdivisions: Ventilation Project (CRC-CI, in progress), aims to verify and quantify the role natural ventilation has in cooling residences in subtropical climates and develop a lot rating methodology for SEQ. This paper reviews results from an industry workshop that explored the current attitudes and methodologies used by a range of professionals involved in subdivision design and development in SEQ. Analysis of the workshop reveals that a key challenge for sustainability is that land development in subtropical SEQ is commonly a separate process from house design and siting. Finally, the paper highlights some of the issues that regulators and industry face in adopting a lot rating methodology for subdivisions offering improved ventilation access, including continuing disagreement between professionals over the desirability of rating tools.