Application of Basic Science to Anesthesia Case File

https://medical-phd.blogspot.com/2021/03/application-of-basic-science-to.html

Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene
C. Toy, MD

Case 5
A 42-year-old woman is undergoing surgery for a bilateral tubal ligation. She has undergone
endotracheal intubation. The medical student, who received a degree in physics in college, notices
that the anesthesiologist is working with the Ambu bag to ventilate the patient. The student
speculates about decreasing the work required by shortening the endotracheal tube (ETT).

➤ If the ETT is shortened by 25%, how would that affect the work of breathing?

ANSWER TO CASE 5:
Application of Basic Science to Anesthesia

Summary: The patient has undergone endotracheal intubation.

➤ Physiologic change: Shortening the endotracheal tube by 25% would decrease the pressure
required, and hence the work of breathing, by about one-third. ANALYSIS

Objectives
1. Review principles of physics.
2. Understand how the above principles are applied to the practice of anesthesiology.

Considerations
Shortening the endotracheal tube would, indeed, theoretically reduce the work of breathing.
However, during laparoscopy, the patient is paralyzed, and the work of breathing is assumed by the
ventilator. Thus, from a practical perspective, it is rarely necessary to shorten the endotracheal tube.

APPROACH TO
Basic Science in Anesthesia

Anesthesia practice involves application of basic science principles on a daily basis. These
principles include fluid mechanics, physical properties of gases, combustion and fires, and
electrical safety.

CLINICAL APPROACH

Fluid Mechanics
An understanding of basic fluid mechanics is important for the understanding of several processes
managed by anesthesiologists in the operating room, such as gas flow and circulation. Most of the
discussion that follows is derived from analysis of noncompressible newtonian fluids. But even
though air and blood do not fall into this category, the concepts still apply.

The word “laminar” comes from the same root as the familiar “lamina” meaning “layers,” and
signifies that in this type of flow the layers do not mix. Laminar flow can be envisioned as flow
down a straight, calm river. The water 

Figure 5–1. Types of flow are illustrated: axisymmetric laminar (top), asymmetric laminar
(middle), and tubulent flow (bottom).

in the middle is flowing fastest and very little water is flowing at the sides; in fact, it can be
described as a parabola. Turbulent flow, however, is more chaotic, and can be envisioned as the
flow of the water as it flows over rocks or around a bend. The “lamina” of the water—and therefore
the energy required to move them—are no longer all moving in the same direction (Figure 5–1).

What determines whether a flow is laminar or turbulent? The first factor to consider is
the properties of the fluid, specifically the kinematic viscosity (ν) which is the ratio of the viscosity
(μ) of the fluid to its density (ρ). Next to be considered are the diameter of the conduit (d) and the
linear velocity of the fluid (v). The ratio of inertia force divided by the viscous force of the fluid is
known as the Reynolds number. A dimensionless quantity, the Reynolds number is defined as:

Reynolds number = vd/v

Flow changes from laminar to turbulent at a Reynolds number of approximately 2300. It is apparent
that for any given conduit and fluid, there will be a defined velocity at which the flow changes from
laminar to turbulent. Turbulence will also occur wherever there is a sharp turn in the conduit,
because the instantaneous velocity at that point increases. 
Why does it matter to an anesthesiologist whether the flow is laminar or turbulent? The Hagen-
Poiseuille equation describes laminar flow:

ΔP = 8μvavgL/r2

where ΔP is the pressure drop across a conduit, v avg represents the average linear velocity, r
represents the radius of the conduit and L represents the length of the conduit. Since v avg is the flow
(Q) divided by the cross-sectional area, for a circular conduit (pipe or tube) this means that

Q = ΔPπr4/8μL

or in other words, flow is proportional to the fourth power of the radius for a given pressure
drop and inversely proportional to the length of the tube. Thus, the larger an i.v., the faster blood
can be administered. Similarly the longer the catheter, the more resistance there is to the flow of
fluids through it.

Turbulent flow, however, is described by a complex equation which considers the frictional
properties of the material through which the fluid is flowing. The equation tells us that turbulent
flow is proportional to the square root of the pressure drop, and the fifth power of the radius.
Turbulent flow is also inversely proportional to the length of the pipe and the density (not the
viscosity) of the fluid.

Clinically, this means that the pressure required to breathe through a 6 mm ID (inner diameter)
endotracheal tube will be approximately three times the pressure required to breathe through an 8
mm ID tube assuming laminar flow. For turbulent flow, the pressure required for the same breath
will be approximately nine times as much. (In practice, such flow would typically be turbulent.)
Shortening the endotracheal tube by 25% would decrease the pressure required, and hence the work
of breathing, by about one-third. Similar comparisons can be made for the (usually laminar) flow
through intravenous catheters and the (usually turbulent) flow through blood vessels.

Physical Properties of Gases

In addition to the fluid properties of a gas, static properties are also important. Although the gases
we use in clinical practice are not “ideal gases,” the qualitative properties of the ideal gas equation
can still be applied:

PV = nRT

where P represents pressure, V represents volume, n represents number of moles, T represents

absolute temperature, and R represents the ideal gas constant.

For example, for any amount of gas at a constant temperature, the product of pressure and volume
will be a constant, so as pressure increases the volume decreases. Thus Boyle law can be
represented:

PV = k or P1V1 = P2V2
Similarly, at a given pressure, a rise in temperature will cause a gas to expand (Charles law.)

The concepts regarding pressure and partial pressure are also key to understanding many aspects of
anesthetic gases. The pressure of a gas mixture (P total) is the same as the atmospheric pressure to
which the mixture is exposed in mm Hg (1 atm = 760 mm Hg). Moreover, the partial pressure of a
gas in a mixture is the same as its proportion of molecules in the mixture (Dalton law).

Ptotal = P1 + P2 +... Pn

For example, in a mixture of 21% oxygen in nitrogen at 760 mm Hg barometric pressure (1 atm of
pressure), the partial pressure of oxygen is 160 mm Hg and the partial pressure of nitrogen is 600
mm Hg. The same mixture of air in a hyperbaric chamber at 1520 mm Hg (2 atm) would have a
partial pressure of oxygen of 320 mm Hg. 

At equilibrium, every liquid also has its own characteristic vapor pressure, which is exclusively a
function of temperature. For example, the vapor pressure of isoflurane at 25°C is 295 mm Hg. So at
room temperature (approximately 22°C), isoflurane exists primarily as a liquid, it must be heated
slightly to enter the gaseous phase. And from the gas laws discussed earlier, it is easy to understand
that the temperature must be constant in order to ensure the output of a specific, known quantity of
isoflurane from the vaporizer.

At 1 atm, a saturated solution of isoflurane in air (such as found inside a vaporizer) would consist
of 295 mm Hg partial pressure of isoflurane, 98 mm Hg partial pressure of oxygen, and 367 mm Hg
partial pressure of nitrogen, or 38.8% isoflurane. In the same hyperbaric chamber at 2 atm, the
mixture would consist of 295 mm Hg partial pressure of isoflurane, 257 mm Hg partial pressure of
oxygen, and 968 mm Hg of nitrogen, or 19.4% isoflurane. Thus using the gas laws, the effect of
varying atmospheric pressure on the output of a vaporizer calibrated at sea level can be understood.
This has a clinical applicability when anesthetizing patients at high altitudes (even as in some parts
of Colorado) or in a hyperbaric chamber.