On the estimation of pulmonary blood flow from CO2 production time series

It may be possible to estimate a nominal pulmonary blood flow (Q) during an exercise stress test via the algorithm used to estimate breath-by-breath alveolar CO2 production. Recently it has been demonstrated that by relating breath-to-breath fluctuations in alveolar CO2 production to breath-to-breath fluctuations in end-tidal CO2, an optimizing parameter related to Q can be determined that can be used to process the CO2 production fluctuations and minimize their variation. However, the reported values of Q using this procedure appear to be biased low. Using a computer simulation of gas exchange, we demonstrate that the estimate of Q is biased low when the nominal lung volume used in the alveolar gas exchange algorithm is too large. Furthermore, alveolar CO2 transport is determined by an integral of alveolar CO2 over the breath time and, thus, is a path-dependent quantity. The use of end-tidal CO2 fluctuations to approximate fluctuations in this integral contributes to an error in the estimation of Q which yields estimates that are biased low. Alternatively, the use of mean alveolar CO2 fluctuations yield more appropriate Q estimates. These results suggest practical implications for estimating effective pulmonary blood flow during an exercise stress test by using breath-to-breath estimates of mean alveolar CO2.