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• W2060944467 abstract "To the Editor:The questions posed in Dr. Sue’s letter are in part related to the semantics of the term “intrapulmonary shunt.” The calculated shunt ratio ( Q˙sp/ Q˙t) expresses a theoretical percentage of total cardiac output returned to the left heart without change in oxygen content from its value in the pulmonary artery. This calculation allows no distinction between the two components of intrapulmonary shunting: 1) “true shunt”—lung areas where the V˙A/ Q˙ = O; and 2) “shunt effect” or “venous admixture”—lung areas where the V˙A/ Q˙ is low, but greater than zero. A semiquantitative clinical distinction between these two components can frequently be made by noting the changes in calculated shunt that occur with varying FIo2 concentrations. However, it must be emphasized that a precise quantitative differentiation between “true shunt” and “venous admixture” cannot be clinically delineated at present.Historically, attempts to resolve this dilemma have been directed towards attempting to eliminate the component of “venous admixture” by administering 100 percent oxygen. Our study clearly documented that calculated intrapulmonary shunt measurements ( Q˙sp/ Q˙t) are significantly increased with 100 percent oxygen administration independent of the patient’s disease state or respiratory care support With that fact established, the clinical intent of isolating the component of true intrapulmonary shunt by administering 100 percent oxygen is invalid and our statement “there is no clinical advantage to making this measurement at an FIo2 of 1.0” is justified.Our studies reveal that the ( Q˙sp/ Q˙t) decreases in most patients as the FIo2 is increased from maintenance to .5, and that the Q˙sp/ Q˙t) is increased as the FIo2 is raised from .5 to 1.0. These data were not included in our publication since they had been previously reported.1Douglas ME Down JB Dannemiller FJ et al.Changes in pulmonary venous admixture with varying inspired oxygen.Anesth Analg (Cleveland). 1976; 55: 688-693Crossref PubMed Scopus (50) Google Scholar This information is consistent with our previously published concept that the optimal maintenance FIo2 is the minimal oxygen concentration that achieves an arterial Po2 of at least 60 mm Hg.2Shapiro BA Harrison RA Walton JR Clinical application of blood gases. 2nd. Year Book Medical Publishers, Chicago1977Google Scholar, 3Shapiro BA Harrison RA Trout CA Clinical application of respiratory care. 2nd. Year Book Medical Publishers, Chicago1979Google ScholarThe clinical relevance of comparing a shunt measurement at a maintainance FIo2 to one at an FIo2 of 0.5 frequently allows for reasonable clinical assessment of changes in “calculated venous admixture.” Although this information is frequently less than optimal, in many patients it is often helpful therapeutically by delineating whether the major component of the intrapulmonary shunt is true shunt or venous admixture.In summary, we would agree with Dr. Sue that it may turn out to be as unsatisfactory to measure intrapulmonary shunting at a reference FIo2 of .5 as it is an FIo2 of 1.0. However, 50 percent oxygen does not appear to create the increases in shunt calculations produced by 100 percent oxygen administration, and furthermore, these iatrogenic increases in “intrapulmonary shunting” are not only misleading, but potentially detrimental to the patients. To the Editor: The questions posed in Dr. Sue’s letter are in part related to the semantics of the term “intrapulmonary shunt.” The calculated shunt ratio ( Q˙sp/ Q˙t) expresses a theoretical percentage of total cardiac output returned to the left heart without change in oxygen content from its value in the pulmonary artery. This calculation allows no distinction between the two components of intrapulmonary shunting: 1) “true shunt”—lung areas where the V˙A/ Q˙ = O; and 2) “shunt effect” or “venous admixture”—lung areas where the V˙A/ Q˙ is low, but greater than zero. A semiquantitative clinical distinction between these two components can frequently be made by noting the changes in calculated shunt that occur with varying FIo2 concentrations. However, it must be emphasized that a precise quantitative differentiation between “true shunt” and “venous admixture” cannot be clinically delineated at present. Historically, attempts to resolve this dilemma have been directed towards attempting to eliminate the component of “venous admixture” by administering 100 percent oxygen. Our study clearly documented that calculated intrapulmonary shunt measurements ( Q˙sp/ Q˙t) are significantly increased with 100 percent oxygen administration independent of the patient’s disease state or respiratory care support With that fact established, the clinical intent of isolating the component of true intrapulmonary shunt by administering 100 percent oxygen is invalid and our statement “there is no clinical advantage to making this measurement at an FIo2 of 1.0” is justified. Our studies reveal that the ( Q˙sp/ Q˙t) decreases in most patients as the FIo2 is increased from maintenance to .5, and that the Q˙sp/ Q˙t) is increased as the FIo2 is raised from .5 to 1.0. These data were not included in our publication since they had been previously reported.1Douglas ME Down JB Dannemiller FJ et al.Changes in pulmonary venous admixture with varying inspired oxygen.Anesth Analg (Cleveland). 1976; 55: 688-693Crossref PubMed Scopus (50) Google Scholar This information is consistent with our previously published concept that the optimal maintenance FIo2 is the minimal oxygen concentration that achieves an arterial Po2 of at least 60 mm Hg.2Shapiro BA Harrison RA Walton JR Clinical application of blood gases. 2nd. Year Book Medical Publishers, Chicago1977Google Scholar, 3Shapiro BA Harrison RA Trout CA Clinical application of respiratory care. 2nd. Year Book Medical Publishers, Chicago1979Google Scholar The clinical relevance of comparing a shunt measurement at a maintainance FIo2 to one at an FIo2 of 0.5 frequently allows for reasonable clinical assessment of changes in “calculated venous admixture.” Although this information is frequently less than optimal, in many patients it is often helpful therapeutically by delineating whether the major component of the intrapulmonary shunt is true shunt or venous admixture. In summary, we would agree with Dr. Sue that it may turn out to be as unsatisfactory to measure intrapulmonary shunting at a reference FIo2 of .5 as it is an FIo2 of 1.0. However, 50 percent oxygen does not appear to create the increases in shunt calculations produced by 100 percent oxygen administration, and furthermore, these iatrogenic increases in “intrapulmonary shunting” are not only misleading, but potentially detrimental to the patients." @default.
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• W2060944467 title "Measurement of Shunt in Respiratory Failure" @default.
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