Pas, A.B. de
Citation
Pas, A. B. de. (2009, March 5). Spontaneous breathing and respiratory support of preterm infants at birth. Retrieved from
https://hdl.handle.net/1887/13595
Version: Corrected Publisher’s Version
License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden
Downloaded from: https://hdl.handle.net/1887/13595
Note: To cite this publication please use the final published version (if applicable).
Positive end expiratory pressure is required to develop a functional residual capacity in preterm
rabbits ventilated from birth
Melissa L. Siew 1; Arjan B. te Pas2; Megan J. Wallace1; Marcus J. Kitchen3; Robert A. Lewis3,4; Andreas Fouras5; Colin J. Morley2; Peter G. Davis2; Naoto Yagi6;
Kentaro Uesugi6 and Stuart B. Hooper1
&9ZeVgibZcid[E]nh^dad\n!(HX]ddad[E]nh^Xh!)BdcVh]8ZcigZ[dgHncX]gdigdcHX^ZcXZVcY!
*9^k^h^dcd[7^dad\^XVa:c\^cZZg^c\!BdcVh]Jc^kZgh^in!BZaWdjgcZ!K>8(-%%!6jhigVa^V#
'CZdcViVaGZhZVgX]!GdnVaLdbZc¼h=dhe^iVa!'%;aZb^c\idcGY!EVg`k^aaZ!K^Xidg^V(%*'!6jhigVa^V
+HEg^c\"-$?6HG>!HVnd!=nd\d+,."*&.-!?VeVc#
Submitted
Abstract
Objective. Id YZiZgb^cZ i]Z Z[[ZXi d[ E::E dc i]Z heVi^Va VcY iZbedgVa eViiZgc d[ ajc\
VZgVi^dc ^c egZiZgb gVWW^i ejeh bZX]Vc^XVaan kZci^aViZY [gdb W^gi] jh^c\ h^bjaiVcZdjh
e]VhZXdcigVhiM"gVn^bV\^c\VcYeaZi]nhbd\gVe]n#
Methods. EgZiZgb gVWW^i ejeh lZgZ YZa^kZgZY Wn XVZhVgZVc hZXi^dc Vi ',Y d[ \ZhiVi^dcVa
V\Z!^bbZY^ViZaneaVXZYl^i]^cVlViZg"ÄaaZYeaZi]nhbd\gVe]]ZVYdjiVcY^bV\ZYVh
i]ZnlZgZbZX]Vc^XVaankZci^aViZY[gdbW^gi]l^i]Z^i]ZgVE::Ed[%Xb='Ddg*Xb='D#I]Z
eZV`^cÅVi^dcegZhhjgZlVh]ZaYXdchiVciVi(*Xb='D#
Results. L^i]djiE::E!\VhdcanZciZgZY^cidi]ZY^hiVaV^glVnhYjg^c\^cÅVi^dc#I]ZY^hiVa
V^glVnhXdaaVehZYYjg^c\Zme^gVi^dcVcYVhVgZhjai!i]Z[jcXi^dcVagZh^YjVaXVeVX^in;G8Y^Y
cdi^cXgZVhZVWdkZi]Zajc\¼hVcVidb^XVaYZVYheVXZkdajbZ'#*£%#-bA$`\#>cXdcigVhi!
kZci^aVi^dcl^i]*Xb='DE::E\gVYjVaan^cXgZVhZYVZgVi^dcd[i]ZY^hiVaV^glVnhl^i]ZVX]
^cÅVi^dcVcYi]ZnY^YcdiXdaaVehZViZcYZme^gVi^dc#I]Z;G8VX]^ZkZY^cejehkZci^aViZY
l^i]E::E&.#.£(#'bA$`\lVhh^\c^ÄXVcian\gZViZgi]Vc^cejehkZci^aViZYl^i]djiE::E
"'#(£(#*bA$`\#
Conclusion. E::E ^h ZhhZci^Va [dg [VX^a^iVi^c\ VZgVi^dc d[ i]Z Y^hiVa V^glVnh! VXXjbjaVi^c\
;G8 VcY egZkZci^c\ Y^hiVa V^glVn XdaaVehZ Vi ZcY"Zme^gVi^dc ^c kZgn egZiZgb gVWW^i ejeh
bZX]Vc^XVaankZci^aViZY[gdbW^gi]#
Introduction
6iW^gi]!i]ZV^glVnhbjhiWZXaZVgZYd[a^fj^YidVaadlV^gZcignVcYi]ZdchZid[ejabdcVgn
\Vh ZmX]Vc\Z &"(! l]^X] egZX^e^iViZh bV_dg X]Vc\Zh ^c XVgY^d"ejabdcVgn e]nh^da"
d\nZhhZci^Va[dgi]ZigVch^i^dcidV^g"WgZVi]^c\)!*#6ai]dj\]V^glVna^fj^YXaZVgVcXZ^h
i]dj\]iidgZhjai[gdbVcdhbdi^X\gVY^Zci^cYjXZYWnCV gZVWhdgei^dc(!+!]nYgdhiVi^X
egZhhjgZh\ZcZgViZYWn^che^gVi^dcbVneaVnVh^\c^ÄXVcigdaZ,!-#6hCV gZ"VWhdgei^kZ
bZX]Vc^hbhVgZ^bbVijgZVcYediZci^Vaancdc"[jcXi^dcVa^ckZgnegZiZgb^c[Vcih(!.!&%!
igVch"ejabdcVgn]nYgdhiVi^XegZhhjgZhbVnWZXg^i^XVa[dgV^glVna^fj^YXaZVgVcXZ^cegZiZgb
^c[Vcih#
>c[VcihWdgckZgnegZiZgb]VkZ^bbVijgZajc\hi]ViVgZhjg[VXiVciYZÄX^Zci!eVgi^Vaana^fj^Y"
ÄaaZYVcYegdcZidXdaaVehZViZcY"Zme^gVi^dc!VcYXdbbdcangZfj^gZVhh^hiZYkZci^aVi^dc
ViW^gi]&&#A^iiaZ^h`cdlcVWdjiegdXZYjgZhi]Vi[VX^a^iViZjc^[dgbajc\VZgVi^dcViW^gi]!
eVgi^XjaVgan^ckZgnegZiZgb^c[Vcih!l]Zci]Zajc\^heVgi^Vaana^fj^Y"ÄaaZYVcY]^\]anhjh"
XZei^WaZ id ^c_jgn &'"&)# 6ai]dj\] kZci^aVi^c\ kZgn egZiZgb ^c[Vcih l^i] V edh^i^kZ ZcY
Zme^gVidgnegZhhjgZE::E]VhbVcnVYkVciV\Zh&*"&-!eVgi^XjaVgan^cegZkZci^c\V^glVn
XdaaVehZ&.!'%!^ihV[[ZXihdcajc\VZgVi^dcViW^gi]VgZjc`cdlc#>[V^glVna^fj^YXaZVgVcXZ
^hbV^cangZ\jaViZYWn]nYgdhiVi^XegZhhjgZh^ci]Z^bbVijgZajc\,"-!i]ZVeea^XVi^dcd[
E::EViW^gi]bVnZc]VcXZV^glVna^fj^YXaZVgVcXZVcYjc^[dgbajc\VZgVi^dc#
E]VhZXdcigVhiM"gVn^bV\^c\E8>XVcbZVhjgZi]ZiZbedgVaVcYheVi^VaeViiZgcd[ajc\
VZgVi^dc[gdbW^gi]^ccZlWdgcgVWW^iejeh,!'&#E8>Zmead^ihi]ZgZ[gVXi^kZ^cYZmY^[[Zg"
ZcXZhWZilZZcV^gVcYlViZgidegdYjXZXdcigVhid[V^g$a^fj^YWdjcYVg^Zh^ci]Zajc\'&"
',#6hVgZhjai!i]Za^fj^Y"ÄaaZY[ZiVaajc\dcanWZXdbZhk^h^WaZ[daadl^c\i]ZZcignd[V^gVi
W^gi]!egdk^Y^c\]^\]gZhdaji^dc^bV\Zhd[VaaV^g"ÄaaZYhigjXijgZh!^cXajY^c\VakZda^,#I]^h
^bV\^c\iZX]c^fjZ^h^YZVa[dgbZVhjg^c\i]ZiZbedgVaVcYheVi^VaeViiZgcd[ajc\VZgVi^dc
VcY]VhWZZcjhZY^chedciVcZdjhanWgZVi]^c\gVWW^iejeh,!-#>ci]^hhijYn!lZ]nedi]Z"
h^oZYi]ViE::E!Veea^ZY[gdbi]ZÄghi^cÅVi^dcV[iZgW^gi]!Zc]VcXZhV^glVna^fj^YXaZVgVcXZ
VcYjc^[dgbajc\VZgVi^dc^ckZgnegZiZgbgVWW^iejeh#Id^ckZhi^\ViZi]^h!lZ^bV\ZYajc\
VZgVi^dc^ckZci^aViZYkZgnegZiZgbgVWW^iejeh[gdbW^gi]!^ci]ZegZhZcXZVcYVWhZcXZd[
E::E!VcYh^bjaiVcZdjhanbZVhjgZYX]Vc\Zh^cajc\\VhkdajbZhjh^c\eaZi]nhbd\gVe]n#
Methods
Experimental procedure
6aaZmeZg^bZcihlZgZVeegdkZYWnHEg^c\"-VcYBdcVh]Jc^kZgh^in¼hHX]ddad[7^dbZY^XVa
HX^ZcXZ¼h6c^bVa:i]^Xh8dbb^iiZZh#HijY^ZhlZgZXdcYjXiZY^cZmeZg^bZciVa]jiX](d[
WZVba^cZ'%7'!^ci]Z7^dbZY^XVa>bV\^c\8ZcigZVii]ZHEg^c\"-hncX]gdigdc^c?VeVc#
6i'-YVnh\ZhiVi^dcVaV\Z<60iZgb2('YVnh!egZ\cVciCZlOZVaVcYl]^iZgVWW^ihc2-
lZgZVcVZhi]Zi^hZYjh^c\egded[daGVe^cdkZi0^#k#0&'b\$`\Wdajh!^cijWViZYVcYVcVZh"
i]Zh^VbV^ciV^cZYWn^hdÅdjgVcZ^c]VaVi^dc&#*")#EjehlZgZZmiZg^dg^hZYWnXVZhVgZVc
hZXi^dc! hZYViZY l^i] hdY^jb eZcidWVgW^idcZ CZbWjiVa0 %#&b\! ^#e#! ^cijWViZY k^V V
igVX]Zdidbn l^i] Vc &-< ijWZ VcY YZa^kZgZY# HedciVcZdjh WgZVi]^c\ lVh egZkZciZY
WZ[dgZ^bV\^c\hiVgiZYWndXXajY^c\i]ZZcYdigVX]ZVaijWZ#>bbZY^ViZanV[iZgYZa^kZgn!i]Z
ejelVheaVXZYkZgi^XVaan^cVlViZg"ÄaaZY)%§8eaZi]nhbd\gVe]l^i]i]Z]ZVYdjiVcY
edh^i^dcZY hd i]Z X]Zhi lVh ^c i]Z eVi] d[ i]Z M"gVn WZVb# I]Z ZcYdigVX]ZVa ijWZ lVh
XdccZXiZYidVhbVaaVc^bVakZci^aVidgH6G"-(%$E08L:VcYkZci^aVi^dcXdbbZcXZYl^i]
i]ZdchZid[^bV\^c\s&"'b^cV[iZgYZa^kZgn#EjehlZgZkZci^aViZYl^i]V^gjh^c\VeZV`
^cÅVi^dcegZhhjgZE>Ed[(*Xb='DVcY&+^cÅVi^dcheZgb^cjiZl^i]V&hZX^cÅVi^dci^bZ#
I]ZnlZgZgVcYdbanVaadXViZYidZ^i]ZgcdE::E%E::EdgVE::Ed[*Xb='D*E::E#>i
lVhcdiedhh^WaZidVaiZgi]ZE::EdgE>EhZii^c\hYjg^c\^bV\^c\Vhi]ZkZci^aVidgXdjaYcdi
WZXdcigdaaZYgZbdiZan#6aaejehlZgZkZci^aViZYVcY^bV\ZY[dg,"&%b^chV[iZgW^gi]VcY
i]Zc`^aaZYl^i]hdY^jbeZcidWVgW^idcZCZbWjiVa0&%%b\$`\0^#e##
Plethysmography
Ajc\V^gkdajbZX]Vc\ZhlZgZbZVhjgZY[gdbW^gi]jh^c\VXjhidbbVYZlViZg"ÄaaZYeaZ"
i]nhbd\gVe]-!'-!Xdbeg^hZYd[Vcjeg^\]i]Z^\]i&'Xb!Xna^cYg^XVaY^VbZiZg('bb!
lViZg"ÄaaZYX]VbWZg!hZVaZYVii]ZideWnVgjWWZgY^Ve]gV\bVcYdeZcidVibdhe]ZgZ
k^VVkZgi^XValViZgXdajbc#I]Zeje¼h]ZVYlVhZmiZg^dg^hZY[gdbi]ZX]VbWZgk^VV]daZ
^c i]Z Y^Ve]gV\b l]^X] [dgbZY V lViZg"i^\]i hZVa VgdjcY i]Z eje¼h cZX`# 8]Vc\Zh ^c
i]dgVX^X kdajbZ YjZ id V^g ^c]VaVi^dc XVjhZY lViZg id bdkZ WZilZZc i]Z X]VbWZg VcY
lViZgXdajbc#I]ZgZhjai^c\egZhhjgZX]Vc\ZhlZgZbZVhjgZYjh^c\VegZhhjgZigVchYjXZg
9IM Eajh IC;"G0 7ZXidc 9^X`^chdc VcY gZXdgYZY Y^\^iVaan EdlZgaVW! 69>chigjbZcih0
HnYcZn!6jhigVa^V#I]ZeaZi]nhbd\gVe]lVhXVa^WgViZYWn^c_ZXi^c\&bAd[lViZgWZ[dgZ
ZVX]ZmeZg^bZci#
Phase contrast X-ray imaging
E]VhZXdcigVhiM"gVn^bV\^c\lVhjhZYid^bV\ZV^gZcign^cidi]Zajc\h[gdbW^gi]id^ckZhi^"
\ViZi]ZgViZVcYheVi^VaeViiZgcd[ajc\VZgVi^dc#H^bjaiVcZdjheaZi]nhbd\gVe]nbZVhjgZY
X]Vc\Zh^c\VhkdajbZh!Vai]dj\]i]^hXdjaYVahdWZdWiV^cZY[gdbi]Z^bV\Zh'-#9ZiV^ah
YZhXg^W^c\ i]Z ^bV\^c\ egdXZYjgZh ]VkZ WZZc gZedgiZY egZk^djhan ,# 7g^ZÅn! i]Z M"gVn
ZcZg\nlVh')`ZK!i]ZejehlZgZ'#%bjehigZVbd[i]ZYZiZXidg:B889!8.&%%"%'0V
*%bhZXZmedhjgZi^bZVcYV&hZX^cÅVi^dci^bZlZgZjhZYidb^c^b^hZbdi^dcWajg#>bV\Z
VXfj^h^i^dcVcYkZci^aVi^dclZgZhncX]gdc^hZYl^i]^cÅVi^dcdchZiig^\\Zg^c\VhZfjZcXZd[
+^bV\Zh(%%bhZX^ciZgkVah#6egZ"dW_ZXih]jiiZgegZkZciZYgVY^Vi^dcZmedhjgZWZilZZc
^bV\ZhVcYi]Zi^b^c\d[^bV\ZVXfj^h^i^dclVhgZXdgYZYY^\^iVaanh^bjaiVcZdjhanl^i]i]Z
eaZi]nhbd\gVe]gZXdgY^c\#
Data and statistical analysis
6aaajc\\VhkdajbZhlZgZVY_jhiZY[dgWdYnlZ^\]i#;G8lVhYZiZgb^cZYVhi]Zajc\\Vh
kdajbZViZcY"Zme^gVi^dcVcYi^YVakdajbZKiVhi]ZkdajbZViZcY"^cÅVi^dcb^cjhi]Z
edhi"^cÅVi^dc;G8Zme^gZY\VhkdajbZ#;G8VcYKikVajZhlZgZVcVkZgV\Zd[(^cÅVi^dch
VcYbZVhjgZYVi^cÅVi^dc*£&^#Z#VkZgV\Zd[^cÅVi^dch)"+!^cÅVi^dc'%£&VcYViZkZgn
'%£&^cÅVi^dch[dg&'%^cÅVi^dch#
I]ZVcVidb^XVaYZVYheVXZ69HkdajbZlVhYZiZgb^cZY[gdbi]Z^bV\ZhVhi]ZkdajbZ
d[ V^g ^c i]Z ajc\ Vi i]Z Äghi VeeZVgVcXZ d[ V ÄcZ heZX`aZ l^i]^c i]Z ^bV\Z# HeZX`a^c\ ^h
XVjhZY Wn i]Z [dXjh^c\ Z[[ZXih d[ bjai^eaZ dkZg"an^c\ V^g$a^fj^Y WdjcYVg^Zh ^c egd_ZXi^dc
l]^X]VXiVhVhZg^Zhd[VWZggVciXdbedjcYgZ[gVXi^kZaZchZh,!'&"'(#HeZX`aZVeeZVgh^c
i]Z^bV\Zl]ZcV^ggZVX]Zhi]ZhbVaaiZgb^cVaV^glVnhVcYZmVXianXdggZhedcYh^ci^b^c\
l^i]VbVg`ZY^cÅZXi^dc^ci]Zajc\egZhhjgZ"kdajbZXjgkZ;^\hi]Zi^b^c\d[^bV\Z
VXfj^h^i^dcdXXjggZY^cjc^hdcl^i]eaZi]nhbd\gVe]kdajbZbZVhjgZbZcih!i]Zajc\\Vh
kdajbZl]ZcheZX`aZÄghiVeeZVgZY^ci]Z^bV\ZXdjaYWZYZiZgb^cZY#I]ZidiVaajc\\Vh
c
20
10 30
0 0 0.5 1.0
b
First appearance of speckle 1.5
2
Volume(mL)
a
Pressure (cmH O)
Figure 1#6egZhhjgZ"kdajbZEKXjgkZd[VcZlWdgcgVWW^iejeYjg^c\^ihÄghi^cÅVi^dcl^i]V^gVcYe]VhZ
XdcigVhiM"gVn^bV\ZhVXfj^gZYViY^[[ZgZcied^cihdci]ZXjgkZVh^cY^XViZYWni]ZVggdlh#>bV\ZWlVh
VXfj^gZY^bbZY^ViZanV[iZgi]Zed^cid[^cÅZXi^dcdci]Z^cÅVi^dca^bWd[i]ZEKXjgkZVcYh]dlhVZgVi^dc
_jhiWZ\^cc^c\^ci]ZY^hiVaV^glVnh#I]Zajc\V^gkdajbZVii]^hed^cilVhiV`ZcidWZi]ZVcVidb^XVaYZVY
heVXZkdajbZ#
kdajbZ b^cjh i]Z 69H kdajbZ egdk^YZY Vc Zhi^bViZ d[ \Vh kdajbZ l^i]^c i]Z iZgb^cVa
V^g hVXh# I]Z 69H kdajbZ lVh hjWigVXiZY [gdb i]Z ajc\ \Vh kdajbZ VcY i]Z VgZV jcYZg
i]ZXjgkZVWdkZi]Z69HkdajbZlVhXVaXjaViZYdkZg(^cÅVi^dch[gdb^cÅVi^dcdchZiid
^cÅVi^dcdchZiVi^cÅVi^dc*!'%VcYZkZgn'%i]^cÅVi^dc[dg&'%^cÅVi^dch#I]Zi^bZi]Zajc\
\VhkdajbZZmXZZYZYi]Z69HkdajbZlVhXVaXjaViZYdkZg(^cÅVi^dchVcYZmegZhhZYVhV
eZgXZciV\Zd[i]ZidiVaYjgVi^dcd[i]Z(^cÅVi^dch#
GZhjaihVgZegZhZciZYVhbZVch£H:B#6ekVajZd[1%#%*lVhXdch^YZgZYhiVi^hi^XVaanh^\c^Ä"
XVci#HijYZcijceV^gZYi"iZhihlZgZjhZYidXdbeVgZY^[[ZgZcXZhWZilZZc\gdjeh#8]Vc\Zh
^c ;G8! Ki! VakZdaVg \Vh kdajbZ VcY YjgVi^dc VWdkZ 69H kdajbZ eZg ^cÅVi^dc dkZg i^bZ
lZgZVcVanoZYjh^c\V'"lVngZeZViZYbZVhjgZhVcVanh^hd[kVg^VcXZ6CDK6l^i]V;^h]Zgh
AZVhiH^\c^ÄXVci9^[[ZgZcXZAH9edhi"]dXiZhi#
Results
Animal data: H^miZZcegZiZgbejeh[gdb-gVWW^ihlZgZkZci^aViZY[gdbW^gi]0-l^i]cd
E::E%E::EVcY-l^i]*Xb='Dd[E::E*E::E#I]Z<6'-#&£%#&kh'-#(£%#'YVnh
VcYbZVcejelZ^\]i(*#(£&#&VcY((#-£'#+\lZgZh^b^aVg^cWdi]\gdjeh#;djgejeh
lZgZZmXajYZY'eZg\gdje[gdb69HkdajbZVcVanhZhYjZidhncX]gdc^oVi^dcegdWaZbh
WZilZZc ^bV\Z VXfj^h^i^dc VcY eaZi]nhbd\gVe] gZXdgY^c\# I]Z XVaXjaViZY 69H kdajbZ
lVhh^b^aVg^c%E::E'#*£%#-bA$`\VcY*E::E(#%£%#(bA$`\ejeh#
Phase contrast X-ray imaging of lung aeration: Bdk^Zhd[ajc\VZgVi^dclZgZXdchigjXiZY
WnXdbe^a^c\i]ZE8M"gVn^bV\ZhhZfjZci^VaanVis&#*mcdgbVaheZZYVcYYZbdchigViZ
i]ZWZcZÄX^VaZ[[ZXid[E::Edcajc\VZgVi^dc[gdbW^gi]#>ci]ZVWhZcXZd[E::EhZZBdk^Z
E::E"&dcY^hX!Vai]dj\]V^gZkZcijVaanZciZgZYVcYVZgViZYi]ZY^hiVa\VhZmX]Vc\ZgZ\^dch
d[i]Zajc\!i]Zajc\hY^YcdigZiV^c\VhViZcY"Zme^gVi^dc[dgViaZVhii]ZÄghi&'%^cÅVi^dch#
CjbZgdjh^cÅVi^dchlZgZgZfj^gZYWZ[dgZV^ggZVX]ZYi]ZiZgb^cVaV^glVnh!l]^X]gZbV^cZY
Wg^ZÅn dcan Yjg^c\ ^cÅVi^dc ;^\ '# 9jg^c\ Zme^gVi^dc! bdhi V^glVnh Z^i]Zg XdaaVehZY dg
gZ"ÄaaZY l^i] a^fj^Y ^c %E::E ejeh! hd i]Vi bjX] d[ i]Z gZhe^gVidgn igZZ lVh jc"VZgViZY
ViZcY"Zme^gVi^dc;^\'0hdbZV^gXdjaYWZhZZcigVeeZY^chbVaaXdcYjXi^c\V^glVnh^c
hdbZejeh#>cXdcigVhi!i]Zajc\hd[ejehkZci^aViZYl^i]*Xb='DE::EhZZBdk^ZE::E"
'dcY^hXVZgViZYgVe^Yan!WZ\^cc^c\^ci]ZaVg\Zegdm^bVaV^glVnhVcYZmiZcY^c\idi]Z
Y^hiVagZ\^dch#Ajc\VZgVi^dc^cXgZVhZYl^i]ZVX]^cÅVi^dcVcYV^glVhgZiV^cZY^cWdi]i]Z
Y^hiVaVcYaVg\ZgXdcYjXi^c\V^glVnhViZcY"Zme^gVi^dc!l^i]cdZk^YZcXZd[ajc\XdaaVehZdg
a^fj^YgZ"Äaa^c\i]ZV^glVnhBdk^Z'0;^\'#Ajc\VZgVi^dc^c*E::EejehlVhcdijc^[dgb!
WZ\^cc^c\^ci]ZVe^XVaadWZh!eVgi^XjaVgani]Zg^\]iVe^XVaadWZ!VcY[daadlZYWnVZgVi^dcd[
i]ZbZY^VaVcYi]ZcWVhVaadWZh#
Figure 2#E]VhZXdcigVhiM"gVn^bV\Zhd[egZiZgbgVWW^iejehkZci^aViZYl^i]%Xb='D%E::E0VXVcY*
Xb='D*E::E0WYd[edh^i^kZZcY"Zme^gVidgnegZhhjgZE::E#>bV\ZhlZgZVXfj^gZYViZ^i]Zg[jcXi^dcVa
gZh^YjVaXVeVX^in;G80VWdgcZVgZcY"^che^gVi^dcXYViVeegdm^bViZani]Z'%i]WgZVi]V[iZgi]ZdchZi
d[kZci^aVi^dc#
%E::E *E::E
:cY"^che^gVi^dc;G8
Functional Residual Capacity (FRC)
6aaejehkZci^aViZYl^i]djiE::E%E::E[V^aZYidVXXjbjaViZV;G8i]ViZmXZZYZYi]Z69H
kdajbZ;^\(#;G8^c%E::Eejeh^cXgZVhZYigVch^Zcianid%#.£%#,bA$`\V[iZgi]ZÄghi*
^cÅVi^dch!WjilVhh^\c^ÄXVciangZYjXZYWn^cÅVi^dch'%VcY)%e1%#%*VcYY^Ycdih^\"
c^ÄXVcianY^[[Zg[gdboZgdi]gdj\]djii]ZgZbV^cYZgd[i]ZZmeZg^bZci#6hVgZhjai!i]ZeZg"
XZciV\Zd[i^bZi]Viajc\\VhkdajbZhlZgZ\gZViZgi]Vci]Z69HkdajbZ^c%E::Eejeh
lVh1'%[dgi]ZÄghi)%^cÅVi^dch!gZbV^c^c\WZadl*%[dgi]ZÄghi&'%^cÅVi^dch;^\h(
)W#I]jh!l^i]djiE::E!ajc\\VhkdajbZhdcan^cXgZVhZYVWdkZi]Z69HkdajbZWg^ZÅn
Yjg^c\!VcYh]dgian!V[iZg^cÅVi^dc#
6aa*E::EejehgVe^YanVXXjbjaViZYV;G8VcY!ViVaai^bZed^cih!]VYVh^\c^ÄXVcian]^\]Zg
;G8i]VcejehkZci^aViZYl^i]cdE::Ee1%#%%&;^\)V#I]Z;G8^cXgZVhZYgVe^Yanid-#)£
'#)bA$`\l^i]^ci]ZÄghi*^cÅVi^dch!id&-#)£&#-bA$`\Wn^cÅVi^dc)%VcYi]ZcgZbV^cZY
Vii]^haZkZa;^\)V#I]jh!^c*E::Eejeh!i]ZeZgXZciV\Zd[i^bZi]Viajc\\VhkdajbZhlZgZ
\gZViZgi]Vci]Z69HkdajbZh^cXgZVhZYid&%%l^i]^ci]ZÄghi*^cÅVi^dchVcYgZbV^cZY
VWdkZi]Z69HkdajbZi]gdj\]djii]ZgZhe^gVidgnXnXaZ;^\)W#
Tidal volume (Vt) and lung compliance
I]ZZme^gZYKi^c%E::EVcY*E::Eejehh^\c^ÄXVcian^cXgZVhZY[gdbi]ZdchZid[kZci^aVi^dc
jci^ai]Z&'%i]^cÅVi^dce1%#%*0;^\h(VcY*V#I]Z^cXgZVhZ^cZme^gZYKi^c*E::Eejeh
Lunggasvolume (mL)
0 0.5 1.0 1.5
2.0 5cmH2O PEEP
Lunggasvolume (mL)
0 0.5 1.0
1.5 0cmH O PEEP2
Figure 3#Ajc\\VhkdajbZh!bZVhjgZYjh^c\eaZi]nhbd\gVe]n!^cegZiZgbgVWW^iejehkZci^aViZY[gdbW^gi]
l^i]Z^i]Zg%Xb='DideeVcZadg*Xb='DWdiidbeVcZad[edh^i^kZZcY"Zme^gVidgnegZhhjgZE::E#I]Z
YdiiZY a^cZ gZegZhZcih i]Z XVaXjaViZY VcVidb^XVa YZVY heVXZ kdajbZ# CdiZ i]Vi ejeh kZci^aViZY l^i] *
Xb='DE::EgVe^YanZhiVWa^h]ZYV[jcXi^dcVagZh^YjVaXVeVX^in;G8l]ZgZVhejehkZci^aViZY^ci]ZVWhZcXZ
d[E::E%Xb=DE::EY^YcdiYZkZadeV;G8#
Breath Number
0 20 40 60 80 100 120
Time above anatomical dead space volume (%) 0 20 40 60 80 100 120 (b)
0 20 40 60 80 100 120
FRC (mL/kg)
-10 -5 0 5 10 15 20 25
0PEEP 5PEEP (a)
Figure 4. (a) I]Z X]Vc\Z ^c [jcXi^dcVa gZh^YjVa XVeVX^in ;G8 l^i] i^bZ bZVhjgZY [gdb W^gi] ^c egZiZgb
gVWW^iejehkZci^aViZY[gdbW^gi]l^i]Z^i]Zg%Xb='D%E::E!ÄaaZYX^gXaZhdg*Xb='D*E::E!deZcX^gXaZh
d[edh^i^kZZcY"Zme^gVidgnegZhhjgZE::E#(b)I]ZeZgXZciV\Zd[i^bZi]Vii]Zajc\\VhkdajbZgZbV^cZY
VWdkZi]ZVcVidb^XVaYZVYheVXZkdajbZ^c%E::EÄaaZYX^gXaZhVcY*E::EdeZcX^gXaZhejeh#;dgZVX]
eje!kVajZhlZgZVkZgV\ZYdkZgV(WgZVi]XnXaZViWgZVi]*£&!'%£&VcYZkZgn'%i]WgZVi]i]ZgZV[iZg#
KVajZhVgZbZVc£H:B#
lVhaZhhi]Vc^c%E::Eejehl^i]^cXgZVh^c\^cÅVi^dccjbWZg#6hVgZhjai!i]ZbZVcKid[
%E::EejehlVhh^\c^ÄXVcian\gZViZgi]Vci]Vid[*E::EejehV[iZg^cÅVi^dc+%e1%#%*;^\
*V#6ii]^hi^bZ!i]ZY^[[ZgZcXZ^cKiWZilZZc%E::EVcY*E::EejehlVhZfjVaidi]Z;G8
^c*E::Eejeh!Vhejeh^cWdi]\gdjehVX]^ZkZYi]ZhVbZajc\\VhkdajbZViZcY"^cÅVi^dc
)*#,£*#+kh)-#'£(#'bA$`\gZheZXi^kZan#=dlZkZg!ViZcY"Zme^gVi^dci]Zajc\\VhkdajbZ
lVh&.#.£(#'bA$`\^c*E::EejehVcY%#.£%#,bA$`\^c%E::Eejeh#GZhe^gVidgnhnhiZb
Xdbea^VcXZ^cXgZVhZYYjg^c\ajc\VZgVi^dc!WjicdY^[[ZgZcXZXdjaYWZYZiZXiZYWZilZZc
i]Z\gdjeh;^\*W#
0 20 40 60 80 100 120
Expired Vt (mL/kg)
0 10 20 30 40 50 60
0PEEP 5PEEP
Breath number
0 20 40 60 80 100 120
Lung compliance (mL/kg/cmH2O)
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
(a)
(b)
Figure 5#>cXgZVhZ^ci^YVakdajbZKi0VVcYajc\Xdbea^VcXZW^cegZiZgbgVWW^iejehkZci^aViZY[gdbW^gi]l^i]
Z^i]Zg%Xb='D%E::E!ÄaaZYX^gXaZhdg*Xb='D*E::E!deZcX^gXaZhd[edh^i^kZZcY"Zme^gVidgnegZhhjgZE::E#
KVajZhVgZbZVc£H:B#
Time-related analysis of gas in the distal airways
I]Zi^bZ·YZeZcYZcigZhigV^cidc\VhZmX]Vc\ZlVhVhhZhhZYWnbZVhjg^c\i]ZeZgXZci"
V\Zd[i^bZheZciViV\VhkdajbZ\gZViZgi]Vci]Z69HkdajbZ;^\)W0hZZVWdkZVcY
i]Zi^bZ"gZaViZY^ciZ\gVad[i]Zajc\\VhkdajbZdkZgV(^cÅVi^dcXnXaZ;^\#+#I]Zajc\
\VhkdajbZi^bZ^ciZ\gVa^cXgZVhZYgVe^Yan^c*E::Eejeh!gZVX]^c\(+#%£'#,bA#hZX$`\Vi
^cÅVi^dc'%!l]^X]lVhh^\c^ÄXVcian\gZViZgi]Vc^c%E::Eejeh+#)£'#%bA#hZX$`\#7n
^cÅVi^dc)%!i]Zajc\\VhkdajbZ^ciZ\gVa]VY^cXgZVhZY[jgi]Zgid))#+£'#+bA#hZX$`\^c
*E::EejehVcYi]ZcgZbV^cZYVii]^haZkZa#>cXdcigVhi!^c%E::Eejehi]Zajc\\VhkdajbZ
^ciZ\gVa^cXgZVhZY[gdb.#*£'#&bA#hZX$`\Vi^cÅVi^dc)%id'(#.£)#%bA#hZX$`\Vi^cÅVi^dc
&'%!l]^X]lVhh^\c^ÄXVcianadlZgi]Vc^c*E::Eejeh;^\+#
Discussion
DjghijYnYZbdchigViZhi]VikZci^aVi^dcd[egZiZgbgVWW^iejeh[gdbW^gi]l^i]*Xb='D
d[ E::E \gZVian ^begdkZh VZgVi^dc d[ i]Z Y^hiVa V^glVnh VcY egZkZcih V^glVn XdaaVehZ Vi
ZcY"Zme^gVi^dchZZBdk^ZE::E"'dcY^hX#6hVgZhjai!ejehkZci^aViZYl^i]*Xb='Dd[
E::EgVe^YanVXXjbjaViZYVc;G8l^i]ZVX]^cÅVi^dc^cXgZVh^c\id&.#.£(#'bA$`\VcY
i]ZY^hiVa\VhZmX]Vc\ZgZ\^dchgZbV^cZY\Vh"ÄaaZYViZcY"Zme^gVi^dc#L^i]djiE::EhZZ
Bdk^ZE::E"&dcY^hX!V^gdcaneZcZigViZYi]ZY^hiVa\VhZmX]Vc\ZgZ\^dchWg^ZÅnYjg^c\
^cÅVi^dcVcYi]ZV^glVnhZ^i]ZgeVgi^VaanXdaaVehZYdggZ"ÄaaZYl^i]a^fj^YViZcY"Zme^gVi^dc#
6hi]ZhZejehlZgZ^cijWViZYVcYhZYViZY!i]ZhZgZhjaihVgZbdhiVeea^XVWaZid^cijWViZY
VecZ^XcZlWdgckZgnegZiZgb^c[Vcih#=dlZkZg!djggZhjaihbVnVahdegdk^YZVcVYY^i^dcVa
ZmeaVcVi^dc[dgi]ZWZcZÄX^VaZ[[ZXihd[Xdci^cjdjhedh^i^kZV^glVnegZhhjgZ8E6E^cVkZgn
egZiZgb^c[Vci#
6^glVna^fj^YgZbdkVaViW^gi]^hi]dj\]iidgZhjai[gdbVYgZcVa^cZ"^cYjXZYVXi^kVi^dcd[
Vb^adg^YZhZch^i^kZhdY^jbX]VccZahl]^X]^cXgZVhZhhdY^jbgZVWhdgei^dci]ZgZWnXgZVi^c\
Vcdhbdi^X\gVY^Zci[dglViZgjeiV`ZVXgdhhi]ZejabdcVgnZe^i]Za^jb(!+#6hi]^hegdXZhh
bVijgZh^caViZ\ZhiVi^dc.!'.!eVgianYjZidi]ZVXi^dcd[Xdgi^hda(%!(&!i]^hbZX]Vc^hb
^hjca^`ZanidWZVXi^kZ^ci]Z^bbVijgZajc\d[kZgnegZiZgb^c[Vcih#I]jh!i]ZbZX]Vc^hbh
Yg^k^c\ V^glVn a^fj^Y XaZVgVcXZ VcY ajc\ VZgVi^dc ^c i]ZhZ ^c[Vcih VgZ jcXaZVg# LZ ]VkZ
gZXZcianhj\\ZhiZYi]ViigVch"Ze^i]Za^Va]nYgdhiVi^XegZhhjgZh\ZcZgViZYYjg^c\^che^gVi^dc
egdk^YZhV]nYgdhiVi^XegZhhjgZ\gVY^Zci[dga^fj^YidaZVkZi]ZV^glVnh,!-#I]ZÄcY^c\
i]ViE::E[VX^a^iViZhV^glVna^fj^YXaZVgVcXZVcYajc\VZgVi^dc^cbZX]Vc^XVaankZci^aViZY
Breath Number
0 20 40 60 80 100 120
Lung gas volume integral (mL.sec/kg)
0 10 20 30 40 50 60
0PEEP 5PEEP
Figure 6#I]Zajc\\VhkdajbZi^bZ^ciZ\gVaVgZVjcYZgi]Zajc\\VhkdajbZXjgkZ^cegZiZgbgVWW^iejeh
kZci^aViZY[gdbW^gi]l^i]Z^i]Zg%Xb='D%E::E!ÄaaZYX^gXaZhdg*Xb='D*E::E!deZcX^gXaZhd[edh^i^kZZcY"
Zme^gVidgnegZhhjgZE::E#KVajZhVgZbZVc£H:B#
ejeh^hXdch^hiZcil^i]i]^hhj\\Zhi^dcVcYegdk^YZh[jgi]ZgZk^YZcXZi]ViigVch"Ze^i]Za^Va
]nYgdhiVi^XegZhhjgZheaVnVc^bedgiVcigdaZ^ci]^hegdXZhh!eVgi^XjaVgan^ci]Z^bbVijgZ
ajc\#
I]Z e]VhZ XdcigVhi M"gVn bdk^Z hZfjZcXZh YZbdchigViZ i]Z edh^i^kZ Z[[ZXi d[ E::E dc
ajc\ VZgVi^dc ^c kZgn egZiZgb gVWW^i ejeh bZX]Vc^XVaan kZci^aViZY [gdb W^gi]# 6ai]dj\]
i]ZheVi^VaeViiZgcd[ajc\VZgVi^dclVhcdijc^[dgb!i]ZZmiZcid[ajc\VZgVi^dc^cXgZVhZY
l^i]ZVX]^cÅVi^dcVcYdcXZVZgViZY!gZ\^dchY^YcdiXdaaVehZdggZ"Äaal^i]a^fj^YYjg^c\
Zme^gVi^dc#I]ZhZdWhZgkVi^dchlZgZhjeedgiZYWneaZi]nhbd\gVe]nbZVhjgZbZcih!YZb"
dchigVi^c\i]Vi;G8gVe^Yan^cXgZVhZYid&.#.£(#'bA$`\!kVajZhh^b^aVgidi]VidWhZgkZY^c
hedciVcZdjhanWgZVi]^c\iZgbejeh-#6hVgZhjai!V[iZgi]ZÄghi*^cÅVi^dch!i]Zajc\\Vh
kdajbZ gZbV^cZY eZgbVcZcian VWdkZ i]Z 69H kdajbZ! Vaadl^c\ \Vh ZmX]Vc\Z id dXXjg
i]gdj\]djii]ZgZhe^gVidgnXnXaZ#L^i]djiE::E!Vai]dj\]\VhZkZcijVaaneZcZigViZY^cid
i]Zajc\eZg^e]Zgn!i]Ze]VhZXdcigVhiM"gVn^bV\Zhh]dli]ViV^glVhcdigZiV^cZY^ci]Z
Y^hiVaV^glVnhVcYhdbZd[i]Z^gXdcYjXi^c\V^glVnh!ViZcY"Zme^gVi^dcBdk^ZE::E"&!;^\
'#I]ZhZdWhZgkVi^dchVgZhjeedgiZYWneaZi]nhbd\gVe]nbZVhjgZbZcih!YZbdchigVi^c\
i]Vil^i]djiE::E!V;G8\gZViZgi]Vci]Z69HkdajbZ(#%£%#(bA$`\XdjaYcdiWZ[dgbZY#
6hVgZhjai!i]ZbZVc\VhkdajbZlVh\gZViZgi]Vci]Z69HkdajbZ[dgaZhhi]Vc*%d[i]Z
i^bZ^c%E::Eejeh#
>ci]Z]ZVai]nbVijgZajc\!\VhZmX]Vc\Z^hcdia^b^iZYWn\VhY^[[jh^dcgViZhVcYVgZYZiZg"
b^cZYWni]Zi]^X`cZhhVcYhjg[VXZVgZVd[i]ZV^g$WaddY\VhWVgg^Zg('VhlZaaVheVgi^Va
egZhhjgZ\gVY^Zcih[dgD'VcY8D'((#=dlZkZg!^cVeVgi^Vaana^fj^Y"ÄaaZY^bbVijgZajc\d[
VegZiZgb^c[Vci!\VhY^[[jh^dcgViZhVgZa^`ZanidWZa^b^iZY!eVgi^XjaVgan[dgD'l]^X]^hbjX]
aZhhY^[[jh^WaZi]Vc8D'('#I]^h^hWZXVjhZi]Zajc\\VhWVgg^Zg^hhigjXijgVaan^bbVijgZ
VcYY^hiVaV^glVnXdaaVehZViZcY"Zme^gVi^dca^b^ihi]ZkdajbZd[\VhVcYi]Zi^bZVkV^aVWaZ
[dg VakZdaVg \Vh ZmX]Vc\Z# 6 fjVci^iVi^kZ VcVanh^h d[ i]^h gZaVi^dch]^e lVh VhhZhhZY Wn
bZVhjg^c\i]Zajc\\VhkdajbZi^bZ^ciZ\gVaVWdkZi]Z69HkdajbZ#I]^h^ciZ\gVagVe^Yan
^cXgZVhZY^c*E::EejehVcYlVhbjX]\gZViZgi]Vc^c%E::Eejeh;^\+!WZXVjhZi]Zajc\
\Vh kdajbZ gZbV^cZY h^\c^ÄXVcian VWdkZ i]Z 69H kdajbZ i]gdj\]dji Zme^gVi^dc# I]jh!
i]Z\VhZmX]Vc\ZediZci^Vad[i]Zajc\!eVgi^XjaVgan[dgdmn\Zc!lVh\gZViZg^c*E::Eejeh
XdbeVgZYid%E::Eejeh[dgi]ZÄghi&'%^cÅVi^dchV[iZgW^gi]#>i^hedhh^WaZi]Vii]ZV[[ZXi
d[E::Edc^cXgZVh^c\WaddYdmn\ZcVi^dcYjg^c\i]ZcZlWdgceZg^dY&*!&+!&-^hYjZid
Vc^cXgZVhZ^ci]Z\VhkdajbZi^bZ^ciZ\gVa#
6[iZgi]ZÄghi&'%^cÅVi^dch!i]ZKilVh\gZViZg^c%E::EejehXdbeVgZYl^i]*E::Eejeh!
YZhe^iZVaaejehWZ^c\kZci^aViZYl^i]i]ZhVbZE>E#6hi]ZkdajbZVieZV`^cÅVi^dclVh
h^b^aVg ^c Wdi] \gdjeh! i]Z Y^[[ZgZcXZ ^c Ki lVh YjZ id i]Z ]^\]Zg ;G8 ^c *E::E ejeh Vh
ajc\\VhkdajbZhYZXgZVhZYidcZVgoZgdViZcY"Zme^gVi^dc^c%E::Eejeh#6eVgi[gdbViZa"
ZXigVjbV!i]^hXdjaYXVjhZ\gZViZgh]ZVghigZhhVcYajc\^c_jgn^c%E::EejehXdbeVgZY
id*E::Eejeh#Di]ZghijY^Zh]VkZh]dlci]ViE::E^cXgZVhZhKi&.!()Wnh]^[i^c\ajc\
kdajbZ^cidVbdgZXdbea^VcigZ\^dcd[i]ZegZhhjgZ"kdajbZXjgkZ#6ai]dj\]i]^hZ[[ZXid[
E::E^hcdi^bbZY^ViZ^ci]ZeVgi^Vaana^fj^Y"ÄaaZYajc\&-!^i^hedhh^WaZi]Vii]ZbVm^bjb
kdajbZhVX]^ZkZYViZcY"^cÅVi^dc^cdjghijYnlZgZXadhZidi]Zided[i]Zeje¼hegZhhjgZ"
kdajbZXjgkZ#I]jh!Vh*E::Eejeh]VYV]^\]Zg;G8!i]ZKibVn]VkZWZZca^b^iZY^ci]ZhZ
ejeh#>ilVhcZXZhhVgnidkZci^aViZejehl^i]VE>Ed[(*Xb='DVhegZa^b^cVgnZmeZg^bZcih
YZbdchigViZYi]ViadlZgE>EhlZgZjcVWaZid^c^i^ViZajc\VZgVi^dcVcY^ilVhcdiedhh^WaZ
idVaiZgi]ZkZci^aVidghZii^c\hYjg^c\^bV\^c\#
E]VhZXdcigVhiM"gVn^bV\^c\egdk^YZhVjc^fjZbVXgdhXde^Xk^Zld[i]Zajc\¼higVch^i^dc
^cidV\Vh"ÄaaZYdg\Vc!YZbdchigVi^c\i]Z^bedgiVcXZd[E::EhZZBdk^ZE::E"&Bdk^Z
E::E"'dcY^hX#I]ZheVi^VaeViiZgcd[ajc\VZgVi^dc^cegZiZgbejehlVhY^[[ZgZciidi]Vi
d[ hedciVcZdjhan WgZVi]^c\ iZgb ejeh -# >c kZci^aViZY egZiZgb ejeh! i]Z Ve^XVa adWZh
VZgViZYÄghil]ZgZVhi]ZbZY^Va$WVhVaadWZhVZgViZYÄghi^chedciVcZdjhanWgZVi]^c\iZgb
ejeh,!'-#6hY^Ve]gV\bVi^XXdcigVXi^dcYg^kZhajc\ZmeVch^dcVcYgZYjXi^dch^cV^glVn
egZhhjgZ Yjg^c\ hedciVcZdjh WgZVi]^c\! ^i ^h cdi hjgeg^h^c\ i]Vi ajc\ VZgVi^dc WZ\^ch ^c
i]ZbZY^Va$WVhVagZ\^dch!eVgi^XjaVganVheVgihd[i]ZX]ZhilVaaYZ[dgbYjg^c\hedciVcZ"
djh WgZVi]^c\ ,# =dlZkZg! Yjg^c\ bZX]Vc^XVa kZci^aVi^dc! i]Z Veea^XVi^dc d[ edh^i^kZ
egZhhjgZidi]ZV^glVnhh]djaYegdk^YZgZaVi^kZanh^b^aVgegZhhjgZ\gVY^ZcihidVe^XVaVcY
WVhVaadWZh!aZVY^c\idjc^[dgbgViZhd[VZgVi^dc#6hegZiZgbejehlZgZkZci^aViZY^cVc
jeg^\]iedh^i^dc!^i^hedhh^WaZi]Vi\gVk^in^cÅjZcXZYi]ZheVi^VaeViiZgcd[ajc\VZgVi^dc
,!]dlZkZg!hedciVcZdjhanWgZVi]^c\ejehlZgZVahdhijY^ZY^cVcjeg^\]iedh^i^dc-#
>i^heZgi^cZciidcdiZi]ViVai]dj\]kZgnegZiZgb]jbVc^c[VcihVgZjhjVaankZci^aViZY^cV
]dg^odciVaedh^i^dc!VcYcdijeg^\]iVh^ci]^hZmeZg^bZci!i]ZZ[[ZXid[E::Edc;G8^h^cYZ"
eZcYZcid[WdYnedh^i^dcjcejWa^h]ZYdWhZgkVi^dch#
I]^hhijYn]Vhh]dlci]VibZX]Vc^XVakZci^aVi^dc[gdbW^gi]l^i]E::E\gZVian^begdkZh
ajc\VZgVi^dcVcY\VhZmX]Vc\ZediZci^Vad[i]Zajc\^bbZY^ViZanV[iZgW^gi]#I]Ze]VhZ
XdcigVhiM"gVn^bV\Zh!XaZVganYZbdchigViZi]ViE::EegZkZcihY^hiVaV^glVnXdaaVehZViZcY"
Zme^gVi^dcVaadl^c\;G8idVXXjbjaViZVcYajc\VZgVi^dcid^cXgZVhZl^i]ZVX]^cÅVi^dc#
I]ZhZ YViV Vahd egdk^YZ [jgi]Zg Zk^YZcXZ id ^cY^XViZ i]Vi igVch"Ze^i]Za^Va ]nYgdhiVi^X
egZhhjgZ\gVY^ZcihXdcig^WjiZidV^glVna^fj^YXaZVgVcXZVcYajc\VZgVi^dcV[iZgW^gi]#
References
&# =ddeZgH7!=VgY^c\G#;ZiVaajc\a^fj^Y/VbV_dgYZiZgb^cVcid[i]Z\gdli]VcY[jcXi^dcVaYZkZadebZci
d[i]Z[ZiVaajc\#8a^c:meE]VgbVXdaE]nh^da&..*0''/'(*"),#
'# =VgY^c\ G! =ddeZg H7# GZ\jaVi^dc d[ ajc\ ZmeVch^dc VcY ajc\ \gdli] WZ[dgZ W^gi]# ? 6eea E]nh^da
&..+0-&&/'%."')#
(# DakZgG:!LVaiZgh9K!L^ahdcB#9ZkZadebZciVagZ\jaVi^dcd[ajc\a^fj^YigVchedgi#6ccjGZkE]nh^da
'%%)0++/,,"&%&#
)# 9VlZh<H#;ZiVaVcYCZdcViVaE]nh^dad\n#8]^XV\d/NZVg7dd`>cX#0&.+-#
*# =ddeZgH7!=VgY^c\G#GdaZd[VZgVi^dc^ci]Ze]nh^dad\^XVaVYVeiVi^dcd[i]Zajc\idV^g"WgZVi]^c\Vi
W^gi]#8jggZciGZhe^gVidgnBZY^X^cZGZk^Zlh'%%*0&'/&-*".*#
+# ?V^cA!:Vidc98#E]nh^dad\nd[[ZiVaajc\Åj^YXaZVgVcXZVcYi]ZZ[[ZXid[aVWdg#HZb^cEZg^cVida'%%+
;ZW0(%&/()")(#
,# =ddeZgH7!@^iX]ZcB?!LVaaVXZB?!NV\^C!JZhj\^@!Bdg\VcB?!ZiVa#>bV\^c\ajc\VZgVi^dcVcYajc\
a^fj^YXaZVgVcXZViW^gi]#;6H:7?'%%,BVn'.0'&/(('."(,#
-# H^ZlB!LVaaVXZB?!@^iX]ZcB?!AZl^hG6!;djgVh6!iZEVh67!ZiVa#>che^gVi^dcgZ\jaViZhi]ZgViZVcY
iZbedgVaeViiZgcd[V^glVna^fj^YXaZVgVcXZViW^gi]#?E]nh^da'%%-0hjWb^iiZY#
.# LVaiZgh9K!GVbhYZc86!DakZgG:#9^WjingnaX6BE^cYjXZhV\ZhiVi^dc"YZeZcYVciVWhdgei^dcd[[ZiVa
ajc\a^fj^Y#?6eeaE]nh^da&..%0+-/'%*)".#
&%# 7Vg`ZgEB!<dlZc8L!AVlhdc::!@cdlaZhBG#9ZXgZVhZYhdY^jb^dcVWhdgei^dcVXgdhhcVhVaZe^i]Z"
a^jbd[kZgnegZbVijgZ^c[Vcihl^i]gZhe^gVidgnY^higZhhhncYgdbZ#?EZY^Vig&..,BVg0&(%(/(,(",#
&&# KZgbVGE#GZhe^gVidgnY^higZhhhncYgdbZd[i]ZcZlWdgc^c[Vci#DWhiZi<ncZXdaHjgk&..*?ja0*%,/*)'"
**#
&'# =^aabVcC=!BdhhI?B!@VaaVejgH<!7VX]jgh`^8!E^aadl??!Eda\aVhZ<G!ZiVa#7g^Z[!aVg\Zi^YVakdajbZ
kZci^aVi^dc^c^i^ViZhajc\^c_jgnVcYVhnhiZb^XgZhedchZ^c[ZiVah]ZZe#6b?GZhe^g8g^i8VgZBZY'%%,
HZe&*0&,++/*,*"-&#
&(# 6iiVgB6!9dccHB#BZX]Vc^hbhd[kZci^aVidg"^cYjXZYajc\^c_jgn^cegZbVijgZ^c[Vcih#HZb^cCZdcVida
'%%'DXi0,*/(*("+%#
&)# 7_dg`ajcYA?!>c\^bVghhdc?!8jghiZYiI!?d]c?!GdWZgihdc7!LZgcZgD!ZiVa#BVcjVakZci^aVi^dcl^i]V
[ZlaVg\ZWgZVi]hViW^gi]Xdbegdb^hZhi]Zi]ZgVeZji^XZ[[ZXid[hjWhZfjZcihjg[VXiVcigZeaVXZbZci^c
^bbVijgZaVbWh#EZY^VigGZh&..,HZe0)'(/()-"**#
&*# B^X]cV?!?dWZ6=!>`Z\Vb^B#Edh^i^kZZcY"Zme^gVidgnegZhhjgZegZhZgkZhhjg[VXiVci[jcXi^dc^cegZiZgb
aVbWh#6b?GZhe^g8g^i8VgZBZY&...6j\0&+%'/+()".#
&+# K^ahigje8I!7_dg`ajcYA?!AVghhdc6!AVX]bVcc7!LZgcZgD#;jcXi^dcVagZh^YjVaXVeVX^inVcYkZci^aVi^dc
]dbd\ZcZ^in^cbZX]Vc^XVaankZci^aViZYhbVaacZdcViZh#?6eeaE]nh^da&..'?ja0,(&/',+"-(#
&,# 9^c\Zg?!Ide[Zg6!HX]VaaZgE!HX]lVgoZG#:[[ZXid[edh^i^kZZcYZme^gVidgnegZhhjgZdc[jcXi^dcVagZh^YjVa
XVeVX^inVcYXdbea^VcXZ^chjg[VXiVci"igZViZYegZiZgb^c[Vcih#?EZg^cViBZY'%%&0'.'/&(,")(#
&- EgdWncB:!=ddeZgH7!9Vg\Vk^aaZE6!BX8Vaa^dcC!8gdhhaZn@!=VgY^c\G!ZiVa#Edh^i^kZZcYZme^gVidgn
egZhhjgZ Yjg^c\ gZhjhX^iVi^dc d[ egZbVijgZ aVbWh gVe^Yan ^begdkZh WaddY \VhZh l^i]dji VYkZghZan
V[[ZXi^c\VgiZg^VaegZhhjgZ#EZY^VigGZh'%%)6j\0*+'/&.-"'%)#
&.# C^ahhdc G! <gdhhbVcc <! GdWZgihdc 7# 6gi^ÄX^Va kZci^aVi^dc d[ egZbVijgZ cZlWdgc gVWW^ih/ Z[[ZXih d[
edh^i^kZZcY"Zme^gVidgnegZhhjgZdcajc\bZX]Vc^XhVcYajc\bdge]dad\n#6XiVEVZY^VigHXVcY&.-%
HZe0+.*/*.,"+%'#
'%# BX8Vcc J<! HX]^aaZg =?! 8VgcZn 9:! <Viid A6! HiZ^cWZg\ ?B! C^ZbVc <;# K^hjVa kVa^YVi^dc d[ i]Z
bZX]Vc^XVahiVW^a^o^c\Z[[ZXihd[edh^i^kZZcY"Zme^gVidgnegZhhjgZVii]ZVakZdaVgaZkZa#?Hjg\GZh'%%&
6j\0..'/((*")'#
'&# AZl^hG6!NV\^C!@^iX]ZcB?!Bdg\VcB?!EV\Vc^c9!H^j@@!ZiVa#9ncVb^X^bV\^c\d[i]Zajc\hjh^c\
m"gVne]VhZXdcigVhi#E]nhBZY7^da'%%*Cdk,0*%'&/*%(&")%#
''# @^iX]ZcB?!EV\Vc^c9!AZl^hG6!NV\^C!JZhj\^@#6cVanh^hd[heZX`aZeViiZgch^ce]VhZXdcigVhi^bV\Zh
d[ajc\i^hhjZ#CjXaZVg>chigjbZcihVcYBZi]dYh^cE]nh^XhGZhZVgX]6'%%*0*)-/')%#
'(# @^iX]ZcB?!EV\Vc^c9!AZl^hG6!NV\^C!JZhj\^@!BjY^ZHI#Dci]Zdg^\^cd[heZX`aZ^cm"gVne]VhZ
XdcigVhi^bV\Zhd[ajc\i^hhjZ#E]nhBZY7^da'%%)HZe'&0).&-/)((*")-#
')# @^iX]ZcB?!AZl^hG6!NV\^C!JZhj\^@!EV\Vc^c9!=ddeZgH7!ZiVa#E]VhZXdcigVhiM"gVn^bV\^c\d[b^XZ
VcYgVWW^iajc\h/VXdbeVgVi^kZhijYn#I]Z7g^i^h]?djgcVad[GVY^dad\n'%%*0,-/&%&-"',#
'*# AZl^hG6!=Vaa8?!=j[idc6E!:kVchH!BZc`G=!6g[Zaa^;!ZiVa#M"gVngZ[gVXi^dcZ[[ZXih/Veea^XVi^dcidi]Z
^bV\^c\d[W^dad\^XVai^hhjZh#7g?GVY^da'%%(BVn0,+.%*/(%&"-#
'+# Hjoj`^N!NV\^C!JZhj\^@#M"gVngZ[gVXi^dc"Zc]VcXZY^bV\^c\VcYVbZi]dY[dge]VhZgZig^ZkVa[dgV
h^beaZdW_ZXi#?djgcVad[HncX]gdigdcGVY^Vi^dc'%%'BVn0./&+%"*#
',# NV\^C!Hjoj`^N!JbZiVc^@!@d]bjgVN!NVbVhV`^@#GZ[gVXi^dc"Zc]VcXZYm"gVn^bV\^c\d[bdjhZajc\
jh^c\hncX]gdigdcgVY^Vi^dchdjgXZ#BZYE]nh&...DXi0'+&%/'&.%"(#
'-# @^iX]ZcB?!AZl^hG6!Bdg\VcB?!LVaaVXZB?!H^ZlBAA!H^j@@L!ZiVa#9ncVb^XbZVhjgZhd[ajc\V^g
kdajbZjh^c\e]VhZXdcigVhiM"gVn^bV\^c\#E]nhBZY7^da'%%-0*(/+%+*",,#
'.# 7gdlcB?!DakZgG:!GVbhYZc86!HigVc\A7!LVaiZgh9K#:[[ZXihd[VYgZcVa^cZVcYd[hedciVcZdjhaVWdjg
dci]ZhZXgZi^dcVcYVWhdgei^dcd[ajc\a^fj^Y^ci]Z[ZiVaaVbW#?E]nh^da&.-(0())/&(,"*'#
(%# LVaaVXZB?!=ddeZgH7!=VgY^c\G#GZ\jaVi^dcd[ajc\a^fj^YhZXgZi^dcWnVg\^c^cZkVhdegZhh^c^c[ZiVa
h]ZZe#6b?E]nh^da&..%0'*-/G&%)"G&&&#
(&# LVaaVXZB?!=ddeZgH7!=VgY^c\G#GdaZd[i]ZVYgZcVa\aVcYh^ci]ZbVijgVi^dcd[ajc\a^fj^YhZXgZidgn
bZX]Vc^hbh^c[ZiVah]ZZe#6b?E]nh^da&..+0',%/G&"G-#
('# LV\cZgE9#9^[[jh^dcVcY8]Zb^XVa"GZVXi^dc^cEjabdcVgn<Vh":mX]Vc\Z#E]nh^daGZk&.,,0*,'/'*,"
(&'#
((# =^aa:E!EdlZg<<!Adc\dA9#BVi]ZbVi^XVaH^bjaVi^dcd[EjabdcVgnD'VcY8D':mX]Vc\Z#6b?E]nh^da
&.,(0''))/.%)"&,#
()# HX]aZhhZa?H!Hjhh`^cY=!?dZa99!7dhhjni6!=VggdaYL=!OVco^>!ZiVa#:[[ZXid[E::EdcgZ\^dcVakZci^aV"
i^dcVcYeZg[jh^dc^ci]ZbZX]Vc^XVaankZci^aViZYegZiZgbaVbW#?CjXaBZY&.-.6j\0(%-/&()'"*%#