SGD

1. SGD: Artificial respiration,
Acclimatization, oxygen therapy,
decompression sickness
Dr. Sai Sailesh Kumar G
Associate Professor
Department of Physiology
RDGMC

2. Indications for artificial respiration
 Respiration fails
 Heart continues to beat

3. Why artificial respiration?
 To maintain vitality of the nerve centers, heart
 To maintain circulation
 To stimulate respiratory centers
 To help respiratory centers to take-up their own
spontaneous rhythm

4. Manual methods of artificial respiration
 Schafer’s method
 Sylvester’s method
 Holger-Neilson Method
 Mouth to mouth breathing
 Eve’s rocking method

5. Schafer’s method
 Subject is laid in prone position
 Pillow is placed underneath the chest
 Head is turned to one side
 Operator kneels down by the side of subject facing
towards his head
 Two hands are placed on the two sides of the lower part
of the chest
 Operator puts his body weight leaning forwards and
presses the loins of the subject

6. Schafer’s method
 Increase in the intra-abdominal pressure
 Diaphragm pushed up
 Air is forced out of lungs
 Operator releases the pressure and comes back to erect
position
 Abdominal pressure falls
 Diaphragm descends
 Air enters the lungs (procedure repeated for 12 times a
minute)

7. Schafer’s method

8. Sylvester’s method
 Subject placed in supine position
 Operator kneels at the head end
 Holds the two arms of subject
 Operator raises the subject’s hands above the head
 Folds the hands back upon the chest
 Compressing the chest wall
 Repeat the movements
 Air enters and leaves lungs

9. Sylvester’s method

10. Holger-Neilson method
 Subject placed in prone position
 Arms abducted at the shoulders
 Elbows remain flexed
 Face is turned to one side and rests on hands
 Mouth is cleaned after wiping out mucus
 Operator kneels down in front of subject facing towards
head
 Two hands placed on two sides of the back of the chest
 Operator puts his weight on subjects back by leaning
forward – compression of chest – expiration

11. Holger-Neilson method
 Subject arms forwards by holding them above the
elbows
 Helps in natural inspiration
 Process repeated for 10-12 times a minute

12. Holger-Neilson method

13. Mouth-to-mouth method
 Subject is laid in the supine position with extended head
 Operator sits by side of subjects head
 Operator holds the lower jaw of subject by one thumb
and index finger
 Clamps the nostrils with the other thumb and index finger
 Operator keeps his mouth over the subjects mouth and
exhales forcibly
 Inflation of lungs and thorax (positive pressure breathing)
 Operator takes off his mouth
 Process repeated 10-20 times for minute

14. Eve’s rocking method
 Patient tied on a stretcher
 Head and feet are alternatively tilted through an
angle of 45 degrees
 8-9 movements are carried out per minute
 7 seconds per each movement
 4 seconds head down - expiration
 3 seconds feet down - inspiration

15. Eve’s rocking method

16. Instrumental methods
 Negative pressure breathing – alternatively
compressing and relaxing chest wall
 Positive pressure breathing – introducing oxygen
directly into the lungs

19. Normal Pressures
 Normally atmospheric pressure or barometric
pressure is about 760 mmHg
 Out of this, contribution of oxygen is 21% that is
pressure of oxygen is 160 mmHg (out of 760 mmHg)
 Alveolar PO2 is 104 mmHg
 As per diffusion, the PO2 should be same in
atmosphere and alveoli. Why it is not same?

20. What happens in high altitudes
 Pressure of oxygen in the atmosphere drops (less
than 160 mmHg)
 Imagine it becomes 130 mmHg
 PO2 of alveoli decreases significantly
 Imagine it may decrease to 60 mmHg or less
 What is the problem??

21. PO2 at high altitude
1. Atmospheric PO2 is 130 mmHg
2. Alveolar PO2 is 60 mmHg
3. PO2 of the Blood entering the lungs is 40 mmHg
4. PO2 of the Blood leaving the lungs is 60 mmHg
5. This is called hypoxemia - abnormally low level of
oxygen in the blood.

22. Effect of hypoxemia
 When PO2 less than 60 mmHg (stimulus)
 Stimulation of peripheral chemo receptors
 Inactivation of potassium channels
 Opening of calcium channels
 Release of neurotransmitter
 Stimulation of nerves (cranial nerves IX and X)
 Sends signals to respiratory centers
 increase in the frequency of motor signals

23. Effect of hypoxemia
 Increase in the frequency of stimulation of
diaphragm
 Increase in the contraction
 Increase in alveolar ventilation
 Increase in the rate and depth of respiration
 Tries to bring more air in
 Imagine it increases PO2 to 80 mmHg

24. PO2 after hypoxemia effect
1. Atmospheric PO2 is 130 mmHg
2. Alveolar PO2 is 80 mmHg
3. PO2 of the Blood entering the lungs is 40 mmHg
4. PO2 of the Blood leaving the lungs is 80 mmHg

25. What happens to stimulus to
PCR?
1. When alveolar PO2 is 80 mmHg
2. PO2 of the Blood entering the lungs is 40 mmHg
3. PO2 of the Blood leaving the lungs is 80 mmHg
4. The movement PO2 increases to 80 mmHg, the
stimulus to PCR goes away
5. No stimulation to DRG and respiration slowdown

26. PCO2 at high altitude
1. As we move to high altitudes, PCO2 also decreases
slightly
2. Say Atmospheric PCO2 decreased to 25 mmHg
3. Alveolar PCO2 is 25 mmHg
4. PCO2 of the Blood entering the lungs is 45 mmHg
(pressure gradient increased)
5. PCO2 of the Blood leaving the lungs is 25 mmHg (more
CO2 goes out)
6. PCO2 decreases in the blood (very bad??)

27. CO2 – Normal Mechanism

28. CO2 – Normal Mechanism
 CO2 easily cross Blood brain barrier
 When PCO2 increases in interstitial fluid of medulla
and CSF, the CO2 reacts with water of the tissues and
forms carbonic acid
 Carbonic acid dissociates and releases hydrogen ions
 Hydrogen ions stimulates the chemo sensitive area
and thus respiration

29. CO2 –Mechanism at high altitude
 PCO2 decreases
 Decrease in H+ ions
 Inhibition of central chemo receptors
 Inhibition of DRG
 Inhibition of VRG
 Decrease in the frequency of action potentials
 Decrease in the alveolar ventilation
 Decrease in the rate and depth of respiration

30. What is happening
 Initially there is hypoxemia
 Increase in ventilation
 Brings PO2 back to normal
 In this process more CO2 moves out
 PCO2 decreases
 Inhibition of CCR
 Decrease in the ventilation
 OPPOSITE ACTIONS

31. Lost more CO2 from body?
 If we breath out more CO2
 Respiratory alkalosis
 PH is very high due to low PO2

32. How your body deals this condition?
 Acclimatization
 Kidney comes into the role
 kidney consists of intercalated cells
 When PH increases in blood (decrease in H+ ions)
 Intercalated cells pumps H+ ions out (into blood)
 Increase in H+ ions (PH back to normal)
 Stimulation of CCR
 Stimulation of respiratory centers
 Increase in the rate and depth of respiration

33. Is this enough?
 No …. Not enough
 Kidney again comes into the role
 When the PO2 decreases (hypoxia)
 When PH increases in blood (decrease in H+ ions)
 Hypoxia inducing factor is released from PCT
 Production of hormone - erythropoietin
 Stimulation of bone marrow
 Increase in RBC (polycythemia) – increase in HB
 Increase in oxygen carrying capacity

34. Is this enough?
 No …. Not enough
 Due to polycythemia there is increase in the
perfusion
 Due to hypoxemia there is increase in the
ventilation
 Increase in ventilation and perfusion
 Good V/P coupling there
 Efficient gaseous exchange

35. Is this enough?
 Yes for short periods stay
 If stay for longer periods angiogenesis takes place
 Angiogenesis - formation of new blood vessels

36. Angiogenesis
 In high altitude PO2 decreases
 Less oxygen supply to tissues
 Endothelial cells of blood vessels releases
vascular endothelial growth factor (VGF)
 Sprouts blood vessels
 More blood vessels
 Angiogenesis

37. Is this enough?
 If stay still very longer periods the shape of chest
wall also changes to large or barrel shape.
 Increase in the diffusion capacity due to increase in
the pulmonary capillary blood volume and increase
in the lung air volume.
 In permanent natives of high altitudes, the number
of mitochondria and cellular enzymes is plentiful
than the sea level habitants. (cellular
acclimatization)

38. Acclimatization
1. Increase in the rate and depth of respiration
2. Increase in the RBC (polycythemia)
3. Normal V/P ratio (efficient gas exchange)
4. Angiogenesis
5. Change in shape of chest

39. How long it takes to climb Everest
1. Entire climb takes 6-9 weeks
2. First week – arrive to base camp
3. Next 3-4 weeks – going up and down the
mountain to establish camps with food, fuel and
oxygen
4. Acclimatization process can not be rushed

40. If you climb Everest very fast???
 Acclimatization will not takes place
 Cerebral edema
 Pulmonary edema
 Called as Acute mountain sickness

41. Cerebral edema at high altitude?
 Low PO2 in systemic circulation
 Vasodilation of blood vessels
 Increase in the blood flow through cerebral blood
vessels
 More fluid loss
 Increase in fluid accumulation
 Cerebral edema

42. Cerebral edema at high altitude?
 Increase in intra cranial pressure
 Head ache
 Increase in Pulse rate
 Herniation of brain that compresses the respiratory
centers
 Death

43. What medications should I carry?
 Acetazolamide (inhibits carbonic anhydrase) and
increases CO2 (stimulates RC)
 Mannitol (relieves cerebral edema)
 Dexamethasone (steroid) – relieves cerebral
edema
 Oxygen supplements

44. pulmonary edema at high altitude?
 Low PO2 in pulmonary circulation
 Vasoconstriction of blood vessels
 Blood is diverted to medium constricted or normal
blood vessels
 Increase in blood flow
 Increase in leak of fluid
 Accumulation of fluid
 Pulmonary edema

45. Chronic mountain sickness
 Seen in individuals who stays for long at high altitudes
 Polycythemia increases viscosity of blood and decreases
the blood flow to the tissues ( oxygen delivery decreases)
 All alveoli now becomes low oxygen state, so
vasoconstriction of all pulmonary blood vessels results in
increase in the arterial pressure and failure of right side of
heart.
 Poorly oxygenated blood
 These individuals recover within days or weeks when they
are moved to low altitudes

46. Deep sea diving
 Descending beneath the sea, the pressure
increases tremendously
 To prevent collapse of lungs, air must be supplied at
very high pressures
 This will expose the blood in the lungs to extremely
high pressure – hyper-barism
 Beyond certain limits, these high pressures cause
major alterations in the body physiology and can be
lethal

47. Physiological effects of deep sea
diving
 Nitrogen narcosis at high nitrogen pressure
 Oxygen toxicity at high pressure
 Carbon dioxide toxicity due to deep sea diving

48. Nitrogen narcosis
 At the sea level pressure, the nitrogen has no significant
effect on body functions
 When the diver remains beneath the sea for an hour or
more and breathing compressed air, the depth at which
the first symptom occurs is 120 feet
 At 120 feet, diver begins to be jovial
 At 150-200 feet, he becomes drowsy
 At 200-250 feet, his strength wanes considerably (
unable to do required work)
 Beyond 250 feet, he becomes useless

49. Nitrogen narcosis
 Similar as alcoholic intoxication
 Also called raptures of the depths
 Mechanism is same as any other gas anesthetics
 Nitrogen dissolves in the fatty substances in the
neural membranes, alters the neuronal excitability

50. Oxygen toxicity at high pressures
 When PO2 of blood increases (say 100 mmHg), there
will be increase in the dissolved oxygen in addition to
that bound to hemoglobin
 Extremely high PO2 (when oxygen is breathed at high
pressures) is detrimental to body tissues
 Causes brain seizures and coma in 30-60 minutes
 These seizures occurs with out warning sign and are
lethal
 Nausea, muscle twitchings, dizziness, disturbance of
vision, irritability and disorientation

51. Oxygen toxicity at high pressures
 Molecular oxygen converts into active form of oxygen called
oxygen free radicals
 One of the most important form of oxygen free radicals is
super oxide free radical and other is peroxide free radical
 Even at normal PO2, these free radicals will be continuously
formed
 Body is equipped with enzymes to remove these free radicals
(oxidases, catalases, superoxide dismutase)
 But when PO2 is above the critical levels, there will be
excessive oxygen free radicals

52. Oxygen toxicity at high pressures
 Free radicals oxidizes the polyunsaturated fatty
acids that are essential components of many of cell
membranes
 Also oxidizes cellular enzymes and damages the
cellular metabolic processes
 Nervous tissues are highly susceptible due to
high lipid content
 Most lethal effect of oxygen toxicity is brain
dysfunction

53. Carbon dioxide toxicity
 Depth alone does not increase the rate of CO2 production in
the body
 As long as diver continues to breath normal tidal volume and
expires the CO2 as it is formed, Alveolar PCO2 will be
normal.
 In certain types of diving gear, diving helmet and some type
of rebreathing apparatus, CO2 will build up.
 Beyond 80 mmHg PCO2, the respiratory centers will be
depressed.
 Respiratory acidosis, narcosis, lethargy and even anesthesia.

54. Decompression sickness
 If a diver stays longer periods beneath the sea,
nitrogen is dissolved in the body
 If he comes to surface suddenly, nitrogen bubbles
are formed in the body fluids (intra or extra cellular)
 Cause minor to serious damage to any area of the
body
 This is called as Decompression sickness
 Also called as Bends, compressed air sickness,
Caisson disease, Diver’s paralysis, Dysbarism

55. Symptoms of Decompression
sickness
 Gas bubbles blocks many blood vessels in different
tissues
 Tissue ischemia and death
 In 85-90% of people, pain in the joints and muscles
of legs and arms (bends)
 In 5-10% of people, paralysis, dizziness or
unconsciousness
 in 2% of people, chokes, shortness of breath,
pulmonary edema and death

56. Prevention and management of
Decompression sickness
 Slow ascent
 Tank decompression
 Using helium oxygen mixture in spite of nitrogen
 Why??

57. Why helium??
 Has only one-fifth of narcotic effect of nitrogen
 The amount of helium dissolves in the body is less
when compared to nitrogen
 Low density of helium keeps the airway resistance
minimum (work of breathing less)

58. SCUBA
 Self Contained Under Water Breathing Apparatus
 Designed by French explorer Jacques Cousteau
 Advantage- Only required amount of air enters the
mask and on expiration, the air can not go back to
tank but instead is expired into the sea
 Limitation – only limited time one can remain
beneath water

59. SCUBA

60. THANK YOU