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Clinical observations suggest that compared with standard apnoeic oxygenation, transnasal humidified rapid-insufflation ventilatory exchange using high-flow nasal oxygenation reduces the rate of carbon dioxide accumulation in patients who are anaesthetised and apnoeic. This suggests that active gas exchange takes place, but the mechanisms by which it may occur have not been described. We used three laboratory airway models to investigate mechanisms of carbon dioxide clearance in apnoeic patients. We determined flow patterns using particle image velocimetry in a two-dimensional model using particle-seeded fluorescent solution; visualised gas clearance in a three-dimensional printed trachea model in air; and measured intra-tracheal turbulence levels and carbon dioxide clearance rates using a three-dimensional printed model in air mounted on a lung simulator. Cardiogenic oscillations were simulated in all experiments. The visualisation experiments indicated that gaseous mixing was occurring in the trachea. With no cardiogenic oscillations applied, mean (SD) carbon dioxide clearance increased from 0.29 (0.04) ml.min-1 to 1.34 (0.14) ml.min-1 as the transnasal humidified rapid-insufflation ventilatory exchange flow rate was increased from 20 l.min-1 to 70 l.min-1 (p = 0.0001). With a cardiogenic oscillation of 20 ml.beat-1 applied, carbon dioxide clearance increased from 11.9 (0.50) ml.min-1 to 17.4 (1.2) ml.min-1 as the transnasal humidified rapid-insufflation ventilatory exchange flow rate was increased from 20 l.min-1 to 70 l.min-1 (p = 0.0014). These findings suggest that enhanced carbon dioxide clearance observed under apnoeic conditions with transnasal humidified rapid-insufflation ventilatory exchange, as compared with classical apnoeic oxygenation, may be explained by an interaction between entrained and highly turbulent supraglottic flow vortices created by high-flow nasal oxygen and cardiogenic oscillations.

Background Nasal High Flow (NHF) therapy delivers flows of heated humidified gases up to 60 LPM (litres per minute) via a nasal cannula. Particles of oral/nasal fluid released by patients undergoing NHF therapy may pose a cross-infection risk, which is a potential concern for treating COVID-19 patients. Methods Liquid particles within the exhaled breath of healthy participants were measured with two protocols: (1) high speed camera imaging and counting exhaled particles under high magnification (6 participants) and (2) measuring the deposition of a chemical marker (riboflavin-5-monophosphate) at a distance of 100 and 500 mm on filter papers through which air was drawn (10 participants). The filter papers were assayed with HPLC. Breathing conditions tested included quiet (resting) breathing and vigorous breathing (which here means nasal snorting, voluntary coughing and voluntary sneezing). Unsupported (natural) breathing and NHF at 30 and 60 LPM were compared. Results Imaging: During quiet breathing, no particles were recorded with unsupported breathing or 30 LPM NHF (detection limit for single particles 33 μm). Particles were detected from 2 of 6 participants at 60 LPM quiet breathing at approximately 10% of the rate caused by unsupported vigorous breathing. Unsupported vigorous breathing released the greatest numbers of particles. Vigorous breathing with NHF at 60 LPM, released half the number of particles compared to vigorous breathing without NHF. Chemical marker tests: No oral/nasal fluid was detected in quiet breathing without NHF (detection limit 0.28 μL/m3). In quiet breathing with NHF at 60 LPM, small quantities were detected in 4 out of 29 quiet breathing tests, not exceeding 17 μL/m3. Vigorous breathing released 200–1000 times more fluid than the quiet breathing with NHF. The quantities detected in vigorous breathing were similar whether using NHF or not. Conclusion During quiet breathing, 60 LPM NHF therapy may cause oral/nasal fluid to be released as particles, at levels of tens of μL per cubic metre of air. Vigorous breathing (snort, cough or sneeze) releases 200 to 1000 times more oral/nasal fluid than quiet breathing (p < 0.001 with both imaging and chemical marker methods). During vigorous breathing, 60 LPM NHF therapy caused no statistically significant difference in the quantity of oral/nasal fluid released compared to unsupported breathing. NHF use does not increase the risk of dispersing infectious aerosols above the risk of unsupported vigorous breathing. Standard infection prevention and control measures should apply when dealing with a patient who has an acute respiratory infection, independent of which, if any, respiratory support is being used. Clinical trial registration ACTRN12614000924651

An accurate understanding of laparoscopic surgical smoke behaviour is essential to enhance the healthcare of patient and operating room staff and to achieve better optical clarity for the surgeon. This work develops a numerical model of surgical smoke behaviour during laparoscopy. A computational fluid dynamics model was created for a rectangular chamber geometry. A “large eddy simulation” (LES) technique was used to solve transport equations, electrosurgery was modelled using a heat-flux boundary condition, and condensation and evaporation models were employed. An experimental study was undertaken to provide the unknown parameters such as surgical smoke generation rate, water evaporation rate, and heat flux at the electrosurgery site in the numerical simulation. The experimental apparatus was composed of a rectangular chamber with two ports; one used for monopolar electrosurgery, and the other for inlet flow. Condensed water on the chamber inner surface, evacuated water vapour and particulate matter, as well as temperature and relative humidity at different locations within the model, were measured. The experiments showed that surgical smoke generated during laparoscopy is composed of 65% water vapour, 11% particulate matter, and 24% volatile matter by mass. It was measured that particulate matter and water vapour were generated at a rate of 1.9 ( ± 0.3 ) mg/s and 11.7 ( ± 0.6 ) mg/s (mean ± SD, n = 8), respectively. The numerical model predicted that approximately 31% - 35% of the generated smoke was evacuated from the outlet port as a relatively high speed flow and the remainder was accumulated close to the upper surface due to buoyancy. The CFD model can be used as a predictive tool to investigate the exposure of operating room staff to surgical smoke, particulate matter deposition on the peritoneum surface and tissue desiccation during electrosurgical procedures.

Subjects receiving nasal high flow (NHF) via wide-bore nasal cannula may experience different levels of positive pressure depending on the individual response to NHF. In this study, airflow in the nasal airway during NHF-assisted breathing is simulated and nasopharyngeal airway pressure numerically computed, to determine whether the relationship between NHF and pressure can be described by a simple equation. Two geometric models are used for analysis. In the first, 3D airway geometry is reconstructed from computed tomography images of an adult nasal airway. For the second, a simplified geometric model is derived that has the same cross-sectional area as the complex model, but is more readily amenable to analysis. Peak airway pressure is correlated as a function of nasal valve area, nostril area and cannula flow rate, for NHF rates of 20, 40 and 60 L/min. Results show that airway pressure is related by a power law to NHF rate, valve area, and nostril area.

Aim The goal of this paper is to quantify upper airway resistance with and without nasal high flow (NHF) therapy. For adults, NHF therapy feeds 30–60 L/min of warm humidified air into the nose through short cannulas which do not seal the nostril. NHF therapy has been reported to increase airway pressure, increase tidal volume (Vt) and decrease respiratory rate (RR), but it is unclear how these findings affect the work done to overcome airway resistance to air flow during expiration. Also, there is little information on how the choice of nasal cannula size may affect work of breathing. In this paper, estimates of airway resistance without and with different NHF flow (applied via different cannula sizes) were made. The breathing efforts required to overcome airway resistance under these conditions were quantified. Method NHF was applied via three different cannula sizes to a 3-D printed human upper airway. Pressure drop and flow rate were measured and used to estimate inspiratory and expiratory upper airway resistances. The resistance information was used to compute the muscular work required to overcome the resistance of the upper airway to flow. Results NHF raises expiratory resistance relative to spontaneous breathing if the breathing pattern does not change but reduces work of breathing if peak expiratory flow falls. Of the cannula sizes used, the large cannula produced the greatest resistance and the small cannula produced the least. The work required to cause tracheal flow through the upper airway was reduced if the RR and minute volume are reduced by NHF. NHF has been observed to do so in COPD patients ( Braunlich et al., 2013 ). A reduction in I:E ratio due to therapy was found to reduce work of breathing if the peak inspiratory flow is less than the flow below which no inspiratory effort is required to overcome upper airway resistance. Conclusion NHF raises expiratory resistance but it can reduce the work required to overcome upper airway resistance via a fall in inspiratory work of breathing, RR and minute volume.

A method for the construction of both rigid and compliant (flexible) transparent flow phantoms of biological flow structures, suitable for PIV and other optical flow methods with refractive-index-matched working fluid is described in detail. Methods for matching the in vivo compliance and elastic wave propagation wavelength are presented. The manipulation of MRI and CT scan data through an investment casting mould is described. A method for the casting of bubble-free phantoms in silicone elastomer is given. The method is applied to fabricate flexible phantoms of the carotid artery (with and without stenosis), the carotid artery bifurcation (idealised and patient-specific) and the human upper airway (nasal cavity). The fidelity of the phantoms to the original scan data is measured, and it is shown that the cross-sectional error is less than 5% for phantoms of simple shape but up to 16% for complex cross-sectional shapes such as the nasal cavity. This error is mainly due to the application of a PVA coating to the inner mould and can be reduced by shrinking the digital model. Sixteen per cent variation in area is less than the natural patient to patient variation of the physiological geometries. The compliance of the phantom walls is controlled within physiologically realistic ranges, by choice of the wall thickness, transmural pressure and Young’s modulus of the elastomer. Data for the dependence of Young’s modulus on curing temperature are given for Sylgard 184. Data for the temperature dependence of density, viscosity and refractive index of the refractive-index-matched working liquid (i.e. water–glycerol mixtures) are also presented.

Nasal high flow (NHF) cannulae are used to deliver heated and humidified air to patients at steady flows ranging from 5 to 50 l/min. In this study, the flow velocities in the nasal cavity across the complete respiratory cycle during natural breathing and with NHF has been mapped in vitro using time-resolved stereoscopic particle image velocimetry (SPIV). An anatomically accurate silicone resin model of a complete human nasal cavity was constructed using CT scan data and rapid prototyping. Physiological breathing waveforms were reproduced in vitro using Reynolds and Womersley number matching and a piston pump driven by a ball screw and stepper motor. The flow pattern in the nasal cavity with NHF was found to differ significantly from natural breathing. Velocities of 2.4 and 3.3 ms−1 occurred in the nasal valve during natural breathing at peak expiration and inspiration, respectively; however, on expiration, the maximum velocity of 3.8 ms−1 occurred in the nasopharynx. At a cannula flow rate of 30 l/min, maximal velocities of 13.6 and 16.5 ms−1 at peak expiration and inspiration, respectively, were both located in the cannula jet within the nasal valve. Results are presented that suggest the quasi-steady flow assumption is invalid in the nasal cavity during natural breathing; however, it was valid with NHF. Cannula flow has been found to continuously flush the nasopharyngeal dead space, which may enhance carbon dioxide removal and increase oxygen fraction.

Knowledge of the airflow characteristics within the nasal cavity with nasal high flow (NHF) therapy and during unassisted breathing is essential to understand the treatment’s efficacy. The distribution and velocity of the airflow in the nasal cavity with and without NHF cannula flow has been investigated using stereoscopic particle image velocimetry at steady peak expiration and inspiration. In vivo breathing flows were measured and dimensionally scaled to reproduce physiological conditions in vitro. A scaled model of the complete nasal cavity was constructed in transparent silicone and airflow simulated with an aqueous glycerine solution. NHF modifies nasal cavity flow patterns significantly, altering the proportion of inspiration and expiration through each passageway and producing jets with in vivo velocities up to 17.0 ms−1 for 30 l/min cannula flow. Velocity magnitudes differed appreciably between the left and right sides of the nasal cavity. The importance of using a three-component measurement technique when investigating nasal flows has been highlighted.

Blood expirated from the nose may leave a characteristic bloodstain at a crime scene which can provide important clues for reconstructing events during a violent assault. Little research has been done on the typical velocities, trajectories and size distribution that can be expected from expirated blood. An experimental fluid dynamics technique known as stereoscopic particle image velocimetry is used in this work to obtain the air velocity field inside and outside the nostrils during exhalation. A numerical model was then used to compute the trajectory of blood drops of 0.5 and 2 mm. The drops were tracked until ground plane impact below the nostril exit. Three heights were investigated, 1.5, 1.6 and 1.7 m. For an expiration flow rate of 32 l/min in vivo, there is a maximum exit velocity from the nostril of approximately 4 m/s, with a 0.5 m/s difference between nostrils. After the drops have traversed the distances investigated, drops of 0.5 and 2 mm in diameter from both nostrils are at a similar velocity. This implies that the gravitational acceleration after the drops leave the jet has the most influence on velocity. It is however shown that exit velocity does affect impact location. Drop size affects both impact location and impact velocity. An increase in height increases the distance traversed. Compared to the 2-mm drop, the 0.5 mm had a lower impact velocity, but its impact location in the ground plane was further from the nostril exit. Understanding the physics of expirated blood flight allows better interpretation of expirated stains at crime scenes.