Failure of these extra-pulmonary mechanical effects causes visceral oedema
Acute High Altitude
Pulmonary and Cerebral Oedema
Scientific analysis from the
perspective of New Paradigms derived from the interpretation of the Respiratory
Pulse and correlated parameters
Author: Américo González-Bogen
Abstract
Alveolar capillary blood hypertension
versus low alveolar air tension is the cause of acute pulmonary oedema
Natural
adaptation and distribution of species on the surface of the Earth is relative
to Altitude. The mass per volume unit of the atmospheric air is the
determinant physical factor and, the Lung in its thoracic ensemble
achieves this task, integrating and balancing blood and air circulations.
Consequently, Man has a limit for his safe displacement in altitude, the
boundaries of which are roughly limited between sea level and about three
thousand meters.
Cyclic contraction of the muscles of the lobular bronchioles produces two simultaneous main mechanical effects:
1.
Decreases the pleural lumen, to
open way for alveolar-capillary blood circulation. Floodgate action.
2.
Decreases the bronchiolar capacity,
increasing the mass per volume unit of the contained air, thus increasing
its molecular expansive forces. Pump action.
The following muscle
relaxation also enables two simultaneous main mechanical effects:
1.
Allows the molecular expansion
of the previously pressurized air, for its displacement towards the alveoli,
expanding them, in balance with the circulating capillary blood, for gas exchange,
while also displacing the oxygenated blood towards the pulmonary veins. Complementary
pump and Press actions
2.
Elastic retraction of the lobular
structure follows, impelling the used air towards the extra-pulmonary airways.
Pneumatic Pump action
Muscles contraction of the lobar bronchi
accomplish a similar mechanical role to that of the lobular bronchioles,
for air intake and distribution among the lobules, and pulmonary blood balanced
circulation, as well as for abdominal press action, also evoking, reflex via, costal
expansion for floodgate action to balance abdominal-thoracic and cranial
blood circulation towards the right ventricle.
Fig 1 Pressure time graph of the Resultant of the lung’s dynamics in its pleural
surface The Respiratory Pulse. Note the maximal inflexion, which clinically
coincides with each autonomic Inspiration of the animal; also note the series
of minor inflexions, which coincides with arterial pulses. (taken from “Fisiodinámica
del Hombre en el Mundo” (1) This is unequivocal
proof of the Lung being a mechanically active organ, under autonomic control
The Respiratory Pulse is the
Resultant, on the pulmonary surface, in the pleural space, of the cyclic
autonomic dynamics of the Lung in its thoracic ensemble, to which it
automatically integrates, via reflex, from the very moment of birth, by means
of the visceral-somatic Pulmo-Diaphragmatic or Vago-Phrenic reflex. This
autonomic dynamics is the organic process for the newborn integration and
adaptation with the Atmosphere of its environment.
Human specie’s adaptation
level is comprised between sea level and about 3000 to 3500 meters; farther on,
pulmonary functional insufficiency shall manifest as the known Acute High
Altitude Sickness and Visceral oedema, for which I propose the name “Syndrome
of Acute Pulmonary Insufficiency at High Altitude”.
The Lung is an organ with a
complex autonomic mechanical activity, performed by two kinds of integrated
dynamic cycles, accomplished by specific structures.
One of these kinds of cycles,
is carried out by the lobar bronchi under command of the Vagus nerve,
for renovation of volume masses of air, simultaneously achieving
integration of the individuals with the Atmosphere, at the geographical level
of the species genetically programmed adaptation, while also performing pulmo-cardio-circulatory
integration and balance, for gas exchange at the alveolar-capillary units,
this latter by means of the other kind of dynamic cycles, performed by the lobular
bronchioles under Sympathetic command
The Primary role
of the Lung is integration and balance of Organic Dynamics and Universal
Dynamics, by means of the Atmosphere, at the very moment of birth and, its
cyclic reaffirmation throughout Life.
Therefore, being
born means the self balanced dynamic integration of the Foetus with the
Atmosphere.
The mass per
volume unit of the air is the physic-mathematical natural factor enabling that
integration.
Living Beings, humans as a
prototype, defined from the perspective of Mechanics, are structural,
functionally integrated models of Mechanics of Fluids, both liquids and
gases, balanced in themselves as with the Atmosphere at the genetic adaptation
level of the species and individuals, to enable renovation and distribution of
similar masses of air among the alveoli, to accomplish gas exchange with the
blood and homogeneous distribution of oxygenated blood among the tissues.
This integrated dynamic balance
of the whole Organic System of Fluids is the role of the Respiratory Apparatus,
accomplished under active command of the Lung and the Central Nervous System’s
rhythm and force control.
Air mass per volume
unit is the physic mathematical factor determining the distribution of species
and individuals at different levels of the Atmosphere, regulated by the Lung,
in accordance with the Inertial Principle
F = m . a, and the balance
programmed in their genes.
Fig
2. Simultaneous graphs of three main parameters. From top to bottoms : 1.
Respiratory Pulse: 2. Intra-pleural sub-atmospheric pressure 3. Abdominal
aortic pulses. The circles defines each lobular alveolo-capillary cycle and the
correspondences with the others parameters. The arrows mark the coincident
inflexion of capillary and arterial pulses. (Taken from “The New Theory of
Respiratory Dynamics”) (2)
The smooth muscles of the intrapulmonary
airways, under control of the Vagus and Sympathetic nerves, when decreases
their capacities, under control of the Vagus and Sympathetic nerves
proportionally increase the expansive molecular force of the contained air,
condition for its cyclic displacement and distension of the structures, in
balance of forces
We can observe, by
comparative analysis of the simultaneous graphs of the Respiratory Pulse and
Pleural Pressure Variations (fig.2) that the starting point of the
Respiratory Pulse’s ascending slope and the following inflexions are simultaneous
with the pleural pressure descent, which evidences a common primary cause and
sequence in the performance of these mechanical phenomena.
I have demonstrated, in this
sense, that the cyclic mechanical process leading to the Respiratory Function
starts by the Vagus discharge to produce pulmonary broncho-constriction and,
according to the bronchial structure and distribution of its muscular fibres as
geodesic networks and sphincters, as described by Miller, determines a
simultaneous decrease in diameter and length of the airways, decreasing their
capacities and simultaneously producing retraction of the pulmonary structure,
this latter with two simultaneous effects:
1.
Increase in
the pleural lumen and proportional decrease in pressure of its content, which
behaves like gases
This
fact allowed me to conclude that the pleural space is filled with vapour of
the pleural liquid; which remains non saturated and, all this must lead us
to infer that there is a narrow cause effect relationship between these two kinds
of mechanical phenomena, and that they must be necessary for specific
and complementary tasks.
2.
The sudden traction of the Diaphragm to evoke its reflex contraction and
functional somatic integration.
Diaphragm-Intercostal-abdominal muscles
belt under Pulmonary-Diaphragmatic, Vagus-Phrenic reflex command, regulates
intrapulmonary gas expansion and the blood circulation balance between
abdominal and thoracic cavities
Fig
3 shows the correlation between the Respiratory Pulse graphs and the thorax
expansion-retraction as graphed in the Pneumogram. (Taken from The New Theory
of Respiratory Dynamics) (2) a)
Pulmo-costal pulse b) Pulmo-diaphragmatic pulse. c) Pneumogram. Arrow 1 shows
the transitional point between two successive Respiratory Pulses, coincident
with the beginning of the pneumogram descent. Arrow 2 shows the top of the
ascending slope of the pulses. The period 1-2 corresponds to
beonchoconstriction and the first part of
the pneumogram descent. Arrow 3 marks the lower point of the pneumogram,
the maximal thorax retraction, which
coincides with the beginning of the molecular expansion of the gases in the air
and also with the beginning of the Lung’s elastic retraction and the relaxation
of the Diaphragm, conditions to start thorax expansion, show in the pneumogram
Mechanical effects derived
from the dynamics of the pulmonary lobes:
Primary role of
the Lung as a thoracic-abdominal press, as well as in a reflex derived
abdominal muscles press and costal wall floodgate actions
We must remember that the
Phrenic nerve innervates the Diaphragm’s central part, while its peripheral
zone is innervated by the four or five lower intercostal nerves, the same that
innervate the muscles of the corresponding intercostal spaces, and the
anterolateral muscles of the abdomen.
We can infer, from these
anatomical features, the chain of potential mechanical effects derived from
stimulation of these nerves and also to understand the reasons for the
functional structure of this somatic muscular belt between the abdomen and the
thorax, which behaves as a simultaneous and complementary abdominal press and
costal wall floodgate.
 |
|
Fig. 4. Phrenic nerve stimulation after sectioning of
the trachea and division of the right Vagus nerve. From top to bottom: 1. Pulmo-costal Respiratory Pulse. 2. Pulmo-diaphragmatic
Respiratory Pulse. 3. Pneumogram. The pulmo-diaphragmatic pulse contrasts
greatly since the detector balloon is in direct contact with the Diaphragm
and detects the effects of its contraction. The pneumogram contour is
no longer a continuous line since it shows a series of small up and down
displacements (jagged aspect) translating the effects of the artificial
contractions of the diaphragm. This is proof of the narrow relationship
of the intercostal innervated muscles with the diaphragm contraction to
integrate the diaphragmatic thorax-abdominal somatic belt as press and
floodgate balanced effects on liquids circulation. |
This muscular belt,
(Diaphragm, abdominal and low-intercostal muscles), coordinated by the lobar
bronchi muscular contraction, via reflex, constitute the main central engine
for balancing the general and pulmonary blood circulation, coordinated
by Vagus nerve discharges, which while producing contraction-retraction of the
bronchial muscles, simultaneously pull from the Diaphragm, stimulating the
Phrenic nerve to start the chain of reflexes.
This viscero-somatic
integration plays a very important role in balancing venous blood circulation
towards the abdomen and thorax, in normal conditions, which is distorted when
the mass of air per volume unit is
inferior to that of the adaptation limit of the human specie and individuals,
which demands maximal Vagus nerve discharges, thus producing maximal
bronchoconstriction with low pulmonary expansion and derived unbalance in
mechanical effects, as is the case at High Altitude
Concurrent factors in the generation of acute high
altitude pulmonary, cerebral and in general visceral oedema
The
atmospheric air mass per volume unit lowers progressively during the ascent.
Consequently, cyclic bronchoconstriction increases to balance the necessary air
mass per volume unit into the airways and alveoli. Meanwhile, the pulmo-diaphragmatic
reflex increases in intensity, with consequent effects:
This
balancing of cause-effects progressively augments in proportion to the nervous
discharges up to their maximal, which
then makes the alveolar capillary balance impossible. This is the absolute
limit of the species adaptation to the Atmosphere. Farther on the unbalance
becomes evident
Organic
procedure:
The lobar bronchi muscular
contraction, when retracting the structure of the Lung, pulls from the
Diaphragm with two simultaneous effects:
This
press action displaces the abdominal fluid streams towards the Pelvis, while
also helping the upper and cranial venous circulation.
2. When the Diaphragm’s central part
contracts, its radial fibres pull from those in its periphery, stimulating
their innervation, to evoke simultaneous contraction of the muscles innervated
by the four or five lower intercostals nerves, so that all the muscles under
common intercostals innervations simultaneously contract once the diaphragmatic
central part begins relaxation. This complex process also evokes two
simultaneous main effects:
2.1 Abdominal press action, by contraction of the abdominal flat muscles. This action favours
circulation of blood and other abdominal fluids towards the right ventricle.
2.2 Floodgate action, by contraction of the named intercostals muscles, which expand
the base of the costal wall, thus widening the mediastinum and pericardial
space, to widen the way for the blood stream displaced towards the right
ventricle
Note that this physiological
process of Mechanics of Fluids is the sequence of facts derived from the
primary Pulmo-Diaphragmatic Reflex, which responds to Vagus nerve
discharges and, its reason for being is to balance the fluids circulation in
the abdomen, as well as between the abdominal cavity and the Thorax and Head,
while also balancing Pulmonary and cardiac reception of blood and its pressures.
If the Lung does not expand
well, because of insufficient air mass, the described press action towards the
abdomen will also be insufficient, disturbing the normal venous blood return
and, the simultaneous intercostals contraction widen the way for blood
circulation towards the right ventricle, with consequent blood re-distribution
and visceral flooding, with consequent pulmonary and cerebral congestion
and oedema.
The above named processes
lead to hypoxemia, cellular hypoxia, decreased diuresis, acid-basic unbalance,
aggravating these pure physical consequences.
The living
organism is a complex System of Fluid’s Mechanics, dynamically integrated and
cyclically balanced, both in itself as with the Atmosphere
The Lung is
the “integrator” and balancing organ, thus identifying it as the organ with the
widest and most important mechanical activity, under complementary coordination
of the autonomic nerve system
The Lung achieves this balanced organic
integration, with complementary reflex mechanical actions by the
thoracic-abdominal somatic belt, via Vagus-Phrenic reflex
Mechanical effects derived from the Lobular-alveolar-capillary dynamics:
Lobular-Alveolar-capillary
floodgate and press effects
The muscular contraction of
the lobular bronchioles generates similar effects to that of the muscle
contraction of the lobar bronchi.
Therefore, when decreasing
the diameters and length of their ways, there is a simultaneous increases in
the contained air pressure, as far as the alveoli, simultaneously increasing
the pleural lumen in each and every lobular sector, leading to two
complementary effects:
1.
Floodgate action at the alveolar-capillary level, opening ways for
pulmonary blood circulation throughout the alveolar capillaries
If the
muscular contraction of the lobular bronchioles increases, to balance the
contained low mass of air per volume unit, it also increases their retraction,
widening the pleural lumen, therefore increasing the arrival of an increased
volume of blood.
Furthermore,
as the air mass per volume unit is lowered, the alveolar gas expansion is also
lowered along with the generated pressure, consequently, the alveolar press
action is insufficient and blood is retained, with pulmonary hypertension and
flooding.
If the
molecular expansive force of the alveolar air is insufficient, neither the
alveolar distension will be big enough to balance gas exchange with the blood,
nor the alveolar-capillary press action will be strong enough, disrupting blood
circulation forwards, with alveolar-capillary hyper-tension, also adding a
factor for retrograde effects towards the pulmonary artery and the Heart,
becoming jet another factor to increase pressure in the pulmonary artery
The course of these phenomena leads to
pulmonary oedema for simple physical reasons, similar to any acute oedema.
These factors also proportionally decrease the volume of oxygenated blood that
must arrive into the left auricle.
Cardiac catheterisation
during acute pulmonary oedema has been reported, revealing pulmonary
hypertension, arterial unsaturation and a normal left atrial pressure (6).
These
signs have a common cause: The pulmonary autonomic dynamics at high altitudes
as manifest at the two levels or sectors of the whole circuit of fluids
circulation:
1. At the
alveolar-capillary level. Under Sympathetic control
The
produced effects are:
Widening
of the pleural lumen, working as a floodgate, increasing the blood stream as
far as the alveolo-capillary units, retained here due to the low press effect
caused by low molecular expansion of the intra alveolar gases. For the same
reason, the venous stream decreases and
the pressure in the left auricle is low.
This
Dynamics at the lobar bronchi and the lobular bronchiolar level obeys the same
natural conception programmed in the genes: Contraction of the Reissessen’
muscle, producing three simultaneous effects:
1.
Abdominal
press, under Vagus command working at the lobar bronchi
2.
Alveolar
press, under Sympathetic command, for two simultaneous effects:
2.1 Oxygen diffusion
balance
2.2 Displacing the oxygenated
blood towards the left auricle
Consequently,
when the air mass at the lobular level is insufficient, Oxygen diffusion will
also be insufficient, causing blood Oxygen unsaturation and low pressure in the
left auricle.
The
simultaneous lobular retraction leads to widening of the pleural lumen with
floodgate effect, increasing the blood stream and, as the press effect is low,
blood is retained with the consequent pressure increase. These are the cardinal
signs of Acute High Altitude Sickness as is believed, characterising the first
step of the sickness.
If
the patient is not removed from the high Altitude, the Central Nervous System
increases its intensity of discharges and rhythm, with negative effects because
of the insufficiency of the alveolar molecular mass, even with maximal nerve
discharges and the blood stream is
retained, causing generalised visceral flood and oedema, best noticed in the
Lung and cerebrum due to their obvious clinical manifestation. A vicious circle
is established, with irreversible damage leading to death
There
is only one cause:
The low mass per volume unit of the atmosphere in altitudes above
the upper limit of the natural adaptation of the human specie and individuals
Consequently,
specific treatment is immediate descent to lower levels
The
macroscopic findings were characteristic of pulmonary oedema. “All viscera
were congested. The right side of the heart was distended with blood and the
left side was empty. There was no cardiac enlargement.The large blood vessels
were normal. In a fulminating case there was 400 ml. Bloodstained effusion in
each pleural cavity” (6)
Low Air Mass per volume unit at High
Altitude is the Cause of Acute Mountain Sickness, the progress of which leads
to visceral oedema and death
The whole
progress of the signs and symptoms of Acute High Altitude Sickness is an open
book showing the dynamic and anatomopathological consequences in the
Organic-Natural sequence of actions and reactions, leading to integral dynamic
balance of the organic fluids circulation, while at the same time also
integrating with Universal Dynamics, mediated by the Earth’s Atmosphere.
In our case
in study, the accelerated mass is that of the mixture of gases of the
air and, the final working force at the alveolar level is the expansive
molecular force of the contained gases; this is the physic-natural
factor determining organic-physical integration and balance for Life
on Earth
In Synthesis,
the most determining factor of organic failure at high altitude is the low
mass per volume unit of the air, which does not satisfy the autonomic
programmed results, according to the Inertial Equation F = m . a
The known anoxic phenomenon
is a consequence that can add secondary effects to the mechanical problem, but
it is never the causal factor.
Prevention and treatment of Acute High
Altitude Sickness must be focused on solving the evident causal factor present
at high altitudes: Low mass of air per volume unit.
Therefore, the prudent way to act must be
not to surpass the physiological limit of the human specie’s adaptation without
the right equipment
The rational method to be
applied must be immediate descent to the adaptation levels of the individual,
which, could be appreciated between sea level and about 3000-3500 meters high,
for our specie
Workers and mountaineers must
be provided with chambers of pressurised air. Additional supply of Oxygen is
not necessary.
Any sign of
transitorily adaptation of an individual to high altitude can lead to dangerous
interpretation, since this sickness represents a real organic emergency of not
ease evaluation and we now know the pathogenesis in progress.
This study also is, in
itself, a proof of the features and interpretations of the Author’s New
Theory of Respiratory Dynamics, (2) so complex and determinant for Life in
the Earth.
References
1.
González-Bogen A. "Fisiodinámica
del Hombre en el Mundo" 1979. Ediciones de la Biblioteca U.C.V. P.O.Box
47004. Caracas 1040, Venezuela.
2. González-Bogen A. "The New Theory of Respiratory
Dynamics". 1985. Ediciones de la Biblioteca. U.C.V.
3. González-Bogen A. "Integración Dinámico-funcional del
Organismo-Viviente" 1989.Ediciones de la Biblioteca. U.C.V.
4. González-Bogen A. International Seminar "The
Respiratory Pulse" Scientific Review. 1992. Year 1. Nº1. 1992. and Year 2.
Nº2. 1993.
5. Web site http://www.the-respiratory-pulse.org.ve/
6. Herbert N Hultgren, M.D., Cesar E Lopez, M.D., Einar Lundberg, M.D., and Harry Miller, B.S. Physiologic Studies of Pulmonary Edema at High Altitude. Circulation volume xxix, March 1964 p 393-408
7. Inder
Singh, C.C. Kapila P.K. Khanna., R.B.
Nanda., and B. D. P., Rao. High Altitude Pulmonary Oedema. The Lancet January
30, 1965 p229-234
Autor: Américo González-Bogen.
A mail agbogen@reacciun.ve/
Institución: Fundación “El Pulso Respiratorio”.
Av. Universitaria. Edif. Caribana 43. Valle Abajo. Caracas 1040. Venezuela.
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