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At least 199 records · Page 11
All sourcesNASA NTRSDOE OSTI
NASA NTRS1993

The heart works against gravity

The circulatory systems of vertebrate animals are closed, and blood leaves and returns to the heart at the same level. It is often concluded, therefore, that the heart works only against the viscous resistance of the system, not against gravity, even in vascular loops above the heart in which the siphon principle operates. However, we argue that the siphon principle does not assist blood flow in superior vascular loops if any of the descending vasculature is collapsible. If central arterial blood pressure is insufficient to support a blood column between the heart and the head, blood flow ceases because of vascular collapse. Furthermore, the siphon principle does not assist the heart even when a continuous stream of blood is flowing in a superior loop. The potential energy gained by blood as it is pumped to the head is lost to friction in partially collapsed descending vessels and thus is not regained. Application of the Poiseuille equation to flow in collapsible vessels is limited; resistance depends on flow rate in partially collapsed vessels with no transmural pressure difference, but flow rate is independent of resistance. Thus the pressure developed by the heart to establish a given flow rate is independent of the resistance occurring in the partially collapsed vessels. The pressure depends only on the height of the blood column and the resistance in the noncollapsed parts of the system. Simple laboratory models, involving water flow in collapsible tubing, dispel the idea that the siphon principle facilitates blood flow and suggest that previously published results may have been affected by experimental artifact.

Review, Tutorial↗
NASA NTRS1984

Thermoregulatory responses of rats to varying environmental temperatures

The peripheral (tail) circulatory responses of six male albino rats were measured at ambient temperatures between 5 and 40 C, using impedance plethysmography. Each animal was anesthetized, instrumented, and placed in a thermal environmental chamber to reach equilibrium. Tail blood flow, respiration rate, heart rate, core temperature, and tail skin temperature were then monitored at each ambient temperature. The mean tail blood flow was significantly higher (p less than 0.05) at 5 C than at 10 C. The mean blood flow increased significantly (p less than 0.01) at each of the temperatures above 10 C. Tail skin temperature and internal body (core) temperature increased significantly with increasing ambient temperature.

Berry, J. J.↗
NASA NTRS2001

Absence of arterial baroreflex modulation of skin sympathetic activity and sweat rate during whole-body heating in humans

1. Prior findings suggest that baroreflexes are capable of modulating skin blood flow, but the effects of baroreceptor loading/unloading on sweating are less clear. Therefore, this project tested the hypothesis that pharmacologically induced alterations in arterial blood pressure in heated humans would lead to baroreflex-mediated changes in both skin sympathetic nerve activity (SSNA) and sweat rate. 2. In seven subjects mean arterial blood pressure was lowered (approximately 8 mmHg) and then raised (approximately 13 mmHg) by bolus injections of sodium nitroprusside and phenylephrine, respectively. Moreover, in a separate protocol, arterial blood pressure was reduced via steady-state administration of sodium nitroprusside. In both normothermia and heat-stress conditions the following responses were monitored: sublingual and mean skin temperatures, heart rate, beat-by-beat blood pressure, skin blood flow (laser-Doppler flowmetry), local sweat rate and SSNA (microneurography from peroneal nerve). 3. Whole-body heating increased skin and sublingual temperatures, heart rate, cutaneous blood flow, sweat rate and SSNA, but did not change arterial blood pressure. Heart rate was significantly elevated (from 74 +/- 3 to 92 +/- 4 beats x min(-1); P < 0.001) during bolus sodium nitroprusside-induced reductions in blood pressure, and significantly reduced (from 92 +/- 4 to 68 +/- 4 beats x min(-1); P < 0.001) during bolus phenylephrine-induced elevations in blood pressure, thereby demonstrating normal baroreflex function in these subjects. 4. Neither SSNA nor sweat rate was altered by rapid (bolus infusion) or sustained (steady-state infusion) changes in blood pressure regardless of the thermal condition. 5. These data suggest that SSNA and sweat rate are not modulated by arterial baroreflexes in normothermic or moderately heated individuals.

Clinical Trial↗
NASA NTRS1994

Cerebral versus systemic hemodynamics during graded orthostatic stress in humans

BACKGROUND: Orthostatic syncope is usually attributed to cerebral hypoperfusion secondary to systemic hemodynamic collapse. Recent research in patients with neurocardiogenic syncope has suggested that cerebral vasoconstriction may occur during orthostatic hypotension, compromising cerebral autoregulation and possibly contributing to the loss of consciousness. However, the regulation of cerebral blood flow (CBF) in such patients may be quite different from that of healthy individuals, particularly when assessed during the rapidly changing hemodynamic conditions associated with neurocardiogenic syncope. To be able to interpret the pathophysiological significance of these observations, a clear understanding of the normal responses of the cerebral circulation to orthostatic stress must be obtained, particularly in the context of the known changes in systemic and regional distributions of blood flow and vascular resistance during orthostasis. Therefore, the specific aim of this study was to examine the changes that occur in the cerebral circulation during graded reductions in central blood volume in the absence of systemic hypotension in healthy humans. We hypothesized that cerebral vasoconstriction would occur and CBF would decrease due to activation of the sympathetic nervous system. We further hypothesized, however, that the magnitude of this change would be small compared with changes in systemic or skeletal muscle vascular resistance in healthy subjects with intact autoregulation and would be unlikely to cause syncope without concomitant hypotension. METHODS AND RESULTS: To test this hypothesis, we studied 13 healthy men (age, 27 +/- 7 years) during progressive lower body negative pressure (LBNP). We measured systemic flow (Qc is cardiac output; C2H2 rebreathing), regional forearm flow (FBF; venous occlusion plethysmography), and blood pressure (BP; Finapres) and calculated systemic (SVR) and forearm (FVR) vascular resistances. Changes in brain blood flow were estimated from changes in the blood flow velocity in the middle cerebral artery (VMCA) using transcranial Doppler. Pulsatility (systolic minus diastolic/mean velocity) normalized for systemic arterial pressure pulsatility was used as an index of distal cerebral vascular resistance. End-tidal PACO2 was closely monitored during LBNP. From rest to maximal LBNP before the onset of symptoms or systemic hypotension, Qc and FBF decreased by 29.9% and 34.4%, respectively. VMCA decreased less, by 15.5% consistent with a smaller decrease in CBF. Similarly, SVR and FVR increased by 62.8% and 69.8%, respectively, whereas pulsatility increased by 17.2%, suggestive of a mild degree of small-vessel cerebral vasoconstriction. Seven of 13 subjects had presyncope during LBNP, all associated with a sudden drop in BP (29 +/- 9%). By comparison, hyperventilation alone caused greater changes in VMCA (42 +/- 2%) and pulsatility but never caused presyncope. In a separate group of 3 subjects, superimposition of hyperventilation during highlevel LBNP caused a further decrease in VMCA (31 +/- 7%) but no change in BP or level of consciousness. CONCLUSIONS: We conclude that cerebral vasoconstriction occurs in healthy humans during graded reductions in central blood volume caused by LBNP. However, the magnitude of this response is small compared with changes in SVR or FVR during LBNP or other stimuli known to induce cerebral vasoconstriction (hypocapnia). We speculate that this degree of cerebral vasoconstriction is not by itself sufficient to cause syncope during orthostatic stress. However, it may exacerbate the decrease in CBF associated with hypotension if hemodynamic instability develops.

NASA Discipline Cardiopulmonary↗
NASA NTRS1980

Hydroelastic effects in the aorta bifurcation zone

The mechanical behavior of the vessels and blood is mathematically analyzed at the point of aortic bifurcation using a homogeneous single layer channel as a model of the aorta. Allowance is made for the fact that the aortic intima is considerably less rigid than the other layers. For analysis of blood flow in the major arteries, the blood is treated as a viscous Newtonian fluid whose movements are described by Navier-Stokes equations and a continuity equation. Blood flow dynamics at the aortic bifurcation are discussed on the basis of the results.

Volmir, A. S.↗
NASA NTRS1981

A comparison of three liquid-ventilation cooling garments during treadmill exercise

A comparative study was made of the heat transfer performance and physiological effects of three different cooling garments used under sealed garments (simulating space suits) on five male subjects, during treadmill exercise. The mean exercise metabolic rate while walking at 0.9 m/s (2 mph) was 464 plus or minus 33 W. An equilibrium condition was never reached during the uncooled suited control runs and the subjects lost approximately two percent of body weight during the exercises. The mean weight loss with an Apollo-type garment was 0.35 plus or minus 0.10 kg, and 0.26 plus or minus 0.11 kg with the full-body cooling patch garment (garment 2). With the partial-coverage cooling patch (garment 3), the weight loss was 0.52 plus or minus 0.12 kg. The data showed an increase in the leg blood flow when the working muscles were not cooled by liquid flow (garment 3), and the arm blood flow remained unchanged with and without liquid cooling to the arms.

Webbon, B.↗
NASA NTRS1994

Bone tissue engineering: the role of interstitial fluid flow

It is well established that vascularization is required for effective bone healing. This implies that blood flow and interstitial fluid (ISF) flow are required for healing and maintenance of bone. The fact that changes in bone blood flow and ISF flow are associated with changes in bone remodeling and formation support this theory. ISF flow in bone results from transcortical pressure gradients produced by vascular and hydrostatic pressure, and mechanical loading. Conditions observed to alter flow rates include increases in venous pressure in hypertension, fluid shifts occurring in bedrest and microgravity, increases in vascularization during the injury-healing response, and mechanical compression and bending of bone during exercise. These conditions also induce changes in bone remodeling. Previously, we hypothesized that interstitial fluid flow in bone, and in particular fluid shear stress, serves to mediate signal transduction in mechanical loading- and injury-induced remodeling. In addition, we proposed that a lack or decrease of ISF flow results in the bone loss observed in disuse and microgravity. The purpose of this article is to review ISF flow in bone and its role in osteogenesis.

Review↗
NASA NTRS1997

Hypergravity Alters the Susceptibility of Cells to Anoxia-Reoxygenation Injury

Gravity is a physical force, much like shear stress or mechanical stretch, and should affect organ and cellular function. Researchers have shown that gravity plays a role in ventilation and blood flow distribution, gas exchange, alveolar size and mechanical stresses within the lung. Short exposure to microgravity produced marked alterations in lung blood flow and ventilation distribution while hypergravity exaggerated the regional differences in lung structure and function resulting in reduced ventilation at the base and no ventilation of the upper half of the lung. Microgravity also decreased metabolic activity in cardiac cells, WI-38 embryonic lung cells, and human lymphocytes. Rats, in the tail-suspended head-down tilt model, experienced transient loss of lung water, contrary to an expected increase due to pooling of blood in the pulmonary vasculature. Hypergravity has also been found to increase the proliferation of several different cell lines (e.g., chick embryo fibroblasts) while decreasing cell motility and slowing liver regeneration following partial hepatectomy. These studies show that changes in the gravity environment will affect several aspects of organ and cellular function and produce major change in blood flow and tissue/organ perfusion. However, these past studies have not addressed whether ischemia-reperfusion injury will be exacerbated or ameliorated by changes in the gravity environment, e.g., space flight. Currently, nothing is known about how gravity will affect the susceptibility of different lung and vascular cells to this type of injury. We conducted studies that addressed the following question: Does the susceptibility of lung fibroblasts, vascular smooth muscle, and endothelial cells to anoxia/reoxygenation injury change following exposure to hypergravity conditions?

McCloud, Henry↗
NASA NTRS1993

Strategies and methodologies to develop techniques for computer-assisted analysis of gas phase formation during altitude decompression

It would be of operational significance if one possessed a device that would indicate the presence of gas phase formation in the body during hypobaric decompression. Automated analysis of Doppler gas bubble signals has been attempted for 2 decades but with generally unfavorable results, except with surgically implanted transducers. Recently, efforts have intensified with the introduction of low-cost computer programs. Current NASA work is directed towards the development of a computer-assisted method specifically targeted to EVA, and we are most interested in Spencer Grade 4. We note that Spencer Doppler Grades 1 to 3 have increased in the FFT sonogram and spectrogram in the amplitude domain, and the frequency domain is sometimes increased over that created by the normal blood flow envelope. The amplitude perturbations are of very short duration, in both systole and diastole and at random temporal positions. Grade 4 is characteristic in the amplitude domain but with modest increases in the FFT sonogram and spectral frequency power from 2K to 4K over all of the cardiac cycle. Heart valve motion appears to characteristic display signals: (1) the demodulated Doppler signal amplitude is considerably above the Doppler-shifted blow flow signal (even Grade 4); and (2) demodulated Doppler frequency shifts are considerably greater (often several kHz) than the upper edge of the blood flow envelope. Knowledge of these facts will aid in the construction of a real-time, computer-assisted discriminator to eliminate cardiac motion artifacts. There could also exist perturbations in the following: (1) modifications of the pattern of blood flow in accordance with Poiseuille's Law, (2) flow changes with a change in the Reynolds number, (3) an increase in the pulsatility index, and/or (4) diminished diastolic flow or 'runoff.' Doppler ultrasound devices have been constructed with a three-transducer array and a pulsed frequency generator.

Powell, Michael R.↗
NASA NTRS1998

Role of nitric oxide in adenosine-induced vasodilation in humans

Vasodilation is one of the most prominent effects of adenosine and one of the first to be recognized, but its mechanism of action is not completely understood. In particular, there is conflicting information about the potential contribution of endothelial factors. The purpose of this study was to explore the role of nitric oxide in the vasodilatory effect of adenosine. Forearm blood flow responses to intrabrachial adenosine infusion (125 microg/min) were assessed with venous occlusion plethysmography during intrabrachial infusion of saline or the nitric oxide synthase inhibitor NG-monomethyl-L-arginine (L-NMMA) (12.5 mg/min). Intrabrachial infusions of acetylcholine (50 microg/min) and nitroprusside (3 microg/min) were used as a positive and negative control, respectively. These doses were chosen to produce comparable levels of vasodilation. In a separate study, a second saline infusion was administered instead of L-NMMA to rule out time-related effects. As expected, pretreatment with L-NMMA reduced acetylcholine-induced vasodilation; 50 microg/min acetylcholine increased forearm blood flow by 150+/-43% and 51+/-12% during saline and L-NMMA infusion, respectively (P<.01, n=6). In contrast, L-NMMA did not affect the increase in forearm blood flow produced by 3 microg/min nitroprusside (165+/-30% and 248+/-41% during saline and L-NMMA, respectively) or adenosine (173+/-48% and 270+/-75% during saline and L-NMMA, respectively). On the basis of our observations, we conclude that adenosine-induced vasodilation is not mediated by nitric oxide in the human forearm.

Non-NASA Center↗
NASA NTRS1974

Hemodynamic studies of the legs under weightlessness

Following exposure to weightlessness, alterations in the return of blood from the legs play a crucial role in orthostatic tolerance and may be an important factor in work tolerance. To investigate some of the hemodynamic mechansism involved, an experiment was performed on the Skylab 3 and Skylab 4 missions to study arterial blood flow, venous compliance, and muscle pumping of blood. Skylab 4 results indicated that the most likely cause of increased blood flow was an increase in cardiac output secondary to increased central venous pressure caused by blood redistribution. Changes in venous compliance are thought to be primarily changes in somatic musculature which is postulated to primarily determine venous compliance of the legs. This was also thought to be demonstrated by the changes in muscle pumping. It is thought that these compliance changes, when taken with the decreased blood volume; provide a basis for the changes seen in orthostatic tolerance, work capacity and lower body negative pressure response.

Thornton, W. E.↗
NASA NTRS1997

Cardiovascular responses of snakes to hypergravity

Snakes have provided useful vertebrate models for understanding circulatory adaptation to gravity, attributable to their elongate body shape and evolutionary diversificaton in terms of ecology and behavior. Recently we have studied cardiovascular responses of snakes to hypergravic acceleration forces produced acutely in the head-to-tail direction (+Gz) on a short-arm centrifuge. Snakes were held in a nearly straight position within a horizontal plastic tube and subjected to a linear force gradient during acceleration. Carotid blood flow provided an integrated measure of cardiovascular performance. Thus, cardiovascular tolerance of snakes to stepwise increments of Gz was measured as the caudal Gz force at which carotid blood flow ceased. Tolerance to increasing Gz varies according to adaptive evolutionary history inferred from the ecology and behavior of species. With respect to data for six species we investigated, multiple regression analysis demonstrates that Gz tolerance correlates with gravitational habitat, independently of body length. Relative to aquatic and non-climbing species, carotid blood flow is better maintained in arboreal or scansorial species, which tolerate hypergravic forces of +2 to +3.5 Gz. Additionally, semi-arboreal rat snakes (Elaphe obsoleta) exhibit plasticity of responses to long-term, intermittent +1.5 Gz stress. Compared to non-acclimated controls, acclimated snakes show greater increases of heart rate during head-up tilt or acceleration, greater sensitivity of arterial pressure to circulating catecholamines, higher blood levels of prostaglandin ratios favorable to maintenance of arterial blood pressure, and medial hypertrophy in major arteries and veins. As in other vertebrates, Gz tolerance of snakes is enhanced by acclimation, high arterial pressure, comparatively large blood volume, and body movements. Vascular studies of snakes suggest the importance to acclimation of local responses involving vascular tissue, in addition to centrally mediated responses to fluid shifts.

Review, Tutorial↗
NASA NTRS1994

Hemodynamic Responses to Head and Neck Cooling

Personal thermoregulatory systems which provide head and neck cooling are used in the industrial and aerospace environments to alleviate thermal stress. However, little information is available regarding the physiologic and circulatory changes produced by routine operation of these systems. The objective of this study was to measure the scalp temperature and circulatory responses during use of one commercially available thermal control system. The Life Support Systems, Inc. Mark VII portable cooling system and a liquid cooling helmet were used in this study. Two EEG electrodes and one skin temperature transducer were placed on the anterior midline of the scalp to measure the scalp blood and temperature. Blood flow was measured using a bipolar impedance rheograph. Ten subjects, seated in an upright position at normal room temperature, were tested at high, medium, moderate, moderate-low and low coolant temperatures. Scalp blood flow was recorded continuously using a computer data acquisition system with a sampling frequency of 200 Hz. Scalp temperature and cooling helmet Inlet temperature was logged periodically during the test period. This study quantifies the effect of head cooling upon scalp temperature and blood flow. These data may also be used to select operational specifications of the head cooling system for biomedical applications such as the treatment of migraine headaches, scalp cooling during chemotherapy, and cooling of multiple sclerosis patients.

Ku, Yu-Tsuan E.↗
NASA NTRS1998

Cardiovascular Responses of Snakes to Gravitational Gradients

Snakes are useful vertebrates for studies of gravitational adaptation, owing to their elongate body and behavioral diversification. Scansorial species have evolved specializations for regulating hemodynamics during exposure to gravitational stress, whereas, such adaptations are less well developed in aquatic and non-climbing species. We examined responses of the amphibious snake,\italicize (Nerodia rhombifera), to increments of Gz (head-to-tail) acceleration force on both a short- and long-arm centrifuge (1.5 vs. 3.7 m radius, from the hub to tail end of snake). We recorded heart rate, dorsal aortic pressure, and carotid arterial blood flow during stepwise 0.25 G increments of Gz force (referenced at the tail) in conscious animals. The Benz tolerance of a snake was determined as the Gz level at which carotid blood flow ceased and was found to be significantly greater at the short- than long-arm centrifuge radius (1.57 Gz vs. 2.0 Gz, respectively; P=0.016). A similar pattern of response was demonstrated in semi-arboreal rat snakes,\italicize{Elaphe obsoleta}, which are generally more tolerant of Gz force (2.6 Gz at 1.5m radius) than are water snakes. The tolerance differences of the two species reflected cardiovascular responses, which differed quantitatively but not qualitatively: heart rates increased while arterial pressure and blood flow decreased in response to increasing levels of Gz. Thus, in both species of snakes, a reduced gradient of Gz force (associated with greater centrifuge radius) significantly decreases the Gz level that can be tolerated.

Hsieh, Shi-Tong T.↗
NASA NTRS1999

Age, splanchnic vasoconstriction, and heat stress during tilting

During upright tilting, blood is translocated to the dependent veins of the legs and compensatory circulatory adjustments are necessary to maintain arterial pressure. For examination of the effect of age on these responses, seven young (23 +/- 1 yr) and seven older (70 +/- 3 yr) men were head-up tilted to 60 degrees in a thermoneutral condition and during passive heating with water-perfused suits. Measurements included heart rate (HR), cardiac output (Qc; acetylene rebreathing technique), central venous pressure (CVP), blood pressures, forearm blood flow (venous occlusion plethysmography), splanchnic and renal blood flows (indocyanine green and p-aminohippurate clearance), and esophageal and mean skin temperatures. In response to tilting in the thermoneutral condition, CVP and stroke volume decreased to a greater extent in the young men, but HR increased more, such that the fall in Qc was similar between the two groups in the upright posture. The rise in splanchnic vascular resistance (SVR) was greater in the older men, but the young men increased forearm vascular resistance (FVR) to a greater extent than the older men. The fall in Qc during combined heat stress and tilting was greater in the young compared with older men. Only four of the young men versus six of the older men were able to finish the second tilt without becoming presyncopal. In summary, the older men relied on a greater increase in SVR to compensate for a reduced ability to constrict the skin and muscle circulations (as determined by changes in FVR) during head-up tilting.

NASA Discipline Cardiopulmonary↗
NASA NTRS1994

Altered thermoregulatory responses after 15 days of head-down tilt

To determine whether extended exposure to a simulation of microgravity alters thermoregulatory reflex control of skin blood flow, six adult males were exposed to 15 days of 6 deg head-down tilt (HDT). On an ambulatory control day before HDT exposure and on HDT day 15 the core temperature of each subject was increased by 0.5 - 1.0 C by whole body heating with a water-perfused suit. Mean skin temperature, oral temperature (T (sub or)), mean arterial pressure, and forearm blood flow were measured throughout the protocol. Forearm vascular conductance (FVC) was calculated from the ratio of forearm blood flow to mean arterial pressure. After HDT exposure, the T(sub or) threshold at which reflex thermally induced increases in FVC began was elevated, whereas the slope of the T(sub or)-FVC relationship after this threshold was reduced. Moreover, normothermic FVC and FVC at the highest common T(sub or) between pre- and post-HDT trials were reduced after HDT. These data suggest that HDT exposure reduces thermoregulatory responses to heat stress. The mechanisms resulting in such an impaired thermoregulatory response are unknown but are likely related to the relative dehydration that accompanies this exposure.

Crandall, Craig G.↗
NASA NTRS1978

Effect of sodium and calcium ingestion on thermoregulation during exercise in man

The effects of hypertonic sodium and calcium ingestion on body temperature during exercise in cool and hot environments are investigated. Rectal and mean skin temperatures, sweat rates and arm and leg total blood flows were measured in men during periods of rest, submaximal exercise and recovery at temperatures of 26.5 C and 39.4 C after ingestion of NaCl and CaCl2 solutions. In both environments, higher rectal temperatures are observed after hypertonic sodium ingestion, which is also associated with attenuated blood flow in the extremities, lower sweat rates and slightly higher skin temperature in the heat, indicating significant thermoregulatory responses. Hypertonic calcium and isotonic sodium cause no temperature change, although calcium caused a reduction of blood flow in the extremities.

Greenleaf, J. E.↗
NASA NTRS2001

Hindlimb unweighting decreases endothelium-dependent dilation and eNOS expression in soleus not gastrocnemius

We tested the hypothesis that hindlimb unweighting (HLU) decreases endothelium-dependent vasodilation and expression of endothelial nitric oxide synthase (eNOS) and superoxide dismutase-1 (SOD-1) in arteries of skeletal muscle with reduced blood flow during HLU. Sprague-Dawley rats (300-350 g) were exposed to HLU (n = 15) or control (n = 15) conditions for 14 days. ACh-induced dilation was assessed in muscle with reduced [soleus (Sol)] or unchanged [gastrocnemius (Gast)] blood flow during HLU. eNOS and SOD-1 expression were measured in feed arteries (FA) and in first-order (1A), second-order (2A), and third-order (3A) arterioles. Dilation to infusion of ACh in vivo was blunted in Sol but not Gast. In arteries of Sol muscle, HLU decreased eNOS mRNA and protein content. eNOS mRNA content was significantly less in Sol FA (35%), 1A arterioles (25%) and 2A arterioles (18%). eNOS protein content was less in Sol FA (64%) and 1A arterioles (65%) from HLU rats. In arteries of Gast, HLU did not decrease eNOS mRNA or protein. SOD-1 mRNA expression was less in Sol 2A arterioles (31%) and 3A arterioles (29%) of HLU rats. SOD-1 protein content was less in Sol FA (67%) but not arterioles. SOD-1 mRNA and protein content were not decreased in arteries from Gast. These data indicate that HLU decreases endothelium-dependent vasodilation, eNOS expression, and SOD-1 expression primarily in arteries of Sol muscle where blood flow is reduced during HLU.

NASA Discipline Cardiopulmonary↗