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Biomedical subjects

A Pesenti

Publications and source records attributed to A Pesenti.

At least 55 records · Page 3Linked to original sources

Adult respiratory distress syndrome due to pulmonary and extrapulmonary causes: CT, clinical, and functional correlations.

PURPOSE: To assess the differences in CT appearance between adult respiratory distress syndrome due to pulmonary disease (ARDSP) and that due to extrapulmonary disease (ARDSEXP) and determine whether the variable appearances of ARDS are due, in part, to the initial pulmonary and systemic causes. MATERIALS AND METHODS: Thirty-three patients, 22 with ARDSP and 11 with ARDSEXP, underwent helical CT shortly after intubation. Two readers evaluated images for the type, extent, and distribution of pulmonary opacities; secondary findings; and correlation with survival and physiologic parameters. RESULTS: In both ARDSP and ARDSEXP, approximately 80% of the lung was abnormal. In ARDSP, ground-glass opacification and consolidation were equally prevalent, whereas in ARDSEXP ground-glass opacification was dominant. Ground-glass opacification was evenly distributed, whereas consolidation tended to be dorsal and caudal. ARDSP often caused asymmetric consolidation, whereas ARDSEXP caused symmetric ground-glass opacification. Air bronchograms were almost universal. Pleural effusions were present in one-half of the patients, and Kerley B lines and pneumatoceles were uncommon. Lung consolidation correlated with the ratio of mean partial pressure of arterial oxygen to fraction of inspired oxygen, shunt fraction, and pulmonary arterial pressure. The patients who died tended to have more consolidation and asymmetric disease. CONCLUSION: ARDSP tends to be asymmetric, with a mix of consolidation and ground-glass opacification, whereas ARDSEXP has predominantly symmetric ground-glass opacification. In both groups, pleural effusions and air bronchograms are common, and Kerley B lines and pneumatoceles are uncommon.

Adult↗

Effects of continuous negative extrathoracic pressure versus positive end-expiratory pressure in acute lung injury patients.

OBJECTIVE: To compare the effects of continuous negative extrathoracic pressure (CNEP) and positive end-expiratory pressure (PEEP) at the same level of transpulmonary pressure. DESIGN: Prospective analysis. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Nine consecutive acute lung injury patients. Patients with cardiac failure and patients with chronic lung disease were excluded from the investigation. INTERVENTIONS: The patients were sedated and paralyzed while receiving mechanical ventilation and were studied in three different conditions: a) using a PEEP of 0 cm H2O (zero end-expiratory pressure); b) using a PEEP of 15 cm H2O; c) using CNEP. CNEP was applied to the thorax and the upper abdomen and its level was chosen to obtain a transpulmonary pressure similar to the one observed at a PEEP of 15 cm H2O. All patients had an arterial catheter, a pulmonary artery catheter, and a thermistor-tip fiberoptic catheter for thermo-dye-dilution in the femoral artery. These catheters were connected to an integrated monitoring system. We also placed an esophageal catheter in each patient to detect esophageal pressure. MEASUREMENTS AND MAIN RESULTS: For each step, we assessed the hemodynamic variations by measuring intravascular pressures (via a pulmonary artery catheter), transmural pressures (computed by subtracting esophageal pressure from intravascular pressure), and blood volumes (derived from the technique of double indicator). The application of CNEP of -20+/-0.7 cm H2O produced a venous admixture and PaO2/FO2 improvement similar to that obtained with a PEEP of 15 cm H2O. This procedure is associated with a higher cardiac index (5.5+/-1.5 vs. 4.6+/-1.2 L/min/m2; p < .05) coupled with lower central venous pressure, pulmonary artery occlusion pressure, and higher transmural pressures and blood volume parameters. CONCLUSIONS: In acute lung injury patients, a CNEP of -20 cm H2O has the capability to obtain transpulmonary pressure and lung function improvement similar to a PEEP of 15 cm H2O. CNEP differs from the positive pressure by increasing the venous return and the preload of the heart, and has no negative effects on cardiac performance.

APACHE↗

Caesarean delivery of a patient with truncus arteriosus.

Truncus arteriosus Type IV is a rare congenital cardiac malformation characterized by agenesis of the pulmonary arteries. Pulmonary perfusion is ensured by bronchial arteries. One common arterial trunk arises from both ventricles and systemic pulmonary and coronary arteries originate from this common vessel. Survival is rare without surgical correction. We report a case of uncorrected truncus arteriosus Type IV in a 28-year-old primigravid woman who underwent caesarean section.

Journal Article↗

End-inspiratory airway occlusion: a method to assess the pressure developed by inspiratory muscles in patients with acute lung injury undergoing pressure support.

We evaluated the end-inspiratory occlusion maneuver as a means to estimate the inspiratory effort during pressure support ventilation (PS). In nine nonobstructed acute lung injury (ALI) patients, we applied four levels of PS (0, 5, 10, 15 cm H2O) to modify the inspiratory effort. End inspiratory occlusions (2 to 3 s) were performed at the end of each experimental period by pushing the inspiratory hold button of the ventilator (Servo 900 C; Siemens, Berlin, Germany). We took the difference between the end-inspiratory occlusion plateau pressure and the airway pressure before the occlusion (PEEP + PS) as an estimate of the inspiratory effort and called it PMI (Pmusc,index). From the esophageal pressure tracing we obtained a reference measurement of the pressure developed by the inspiratory muscles at end inspiration (Pmusc,ei) and of the pressure-time product per breath (PTP/b) and per minute (PTP/min). In each patient, PMI was correlated with Pmusc,ei (p < 0.01) and PTP/b (p < 0.01). A PMI threshold of 6 cm H2O detected PTP/min < 125 cm H2O s/min with a sensitivity of 0.89 and a specificity of 0.89. We conclude that PMI is a good estimate of the pressure developed by the inspiratory muscles in ALI patients and may be used to titrate PS level. The major advantage of PMI is that it can be obtained from the ventilator display without any additional equipment.

Acute Disease↗

Lung and chest wall mechanics in normal anaesthetized subjects and in patients with COPD at different PEEP levels.

In order to assess the relative contribution of the lung and the chest wall to the derangements of respiratory mechanics in chronic obstructive pulmonary disease (COPD) patients with acute ventilatory failure (AVF), we studied eight COPD patients undergoing controlled mechanical ventilation for AVF and nine normal subjects anaesthetized for surgery as a control group. With the use of the interrupter technique together with the oesophageal balloon technique we measured: static lung and chest wall elastances (E[st,L] and E[st,w], respectively), maximum (R[L,max]), minimum (R[L,min]) and additional (deltaR[L]) lung resistances, additional chest wall resistance (deltaRw) and, in the COPD group, total intrinsic positive end-expiratory pressure (PEEPtot). Measurements were repeated at 0, 5, 10 and 15 cmH2O of applied positive end-expiratory pressure (PEEP). We found that, in the COPD group: 1) both E(st,w) and deltaRw were higher than in the normal group; 2) R(L,max) was markedly increased due to an increase of both R(L,min) and deltaRL; 3) even low levels of PEEP increased PEEPtot; 4) PEEP did not reduce elastance or total resistance of either the lung or the chest wall. We conclude that chest wall mechanics are abnormal in chronic obstructive pulmonary disease patients with acute ventilatory failure undergoing controlled mechanical ventilation and that positive end-expiratory pressure does not seem to be effective in reducing either elastance or resistance of the lung or chest wall.

Anesthesia, General↗

Relief of hypoxemia contributes to a reduction in cardiac index related to the use of positive end-expiratory pressure.

OBJECTIVE: We have investigated the role that improvement in arterial oxygenation has, consequent on positive end-expiratory pressure (PEEP), in the reduction of cardiac index (CI) determined by applying PEEP. DESIGN: 2 x 2 factorial trial. SETTING: Department of intensive care medicine at a university hospital. PATIENTS: 13 patients on mechanical ventilation for acute lung injury. INTERVENTIONS: Four experimental conditions, each one characterized by one level of PEEP and one level of PaO2: LOLP = Low PaO2 (approximately 50 mmHg) Low PEEP (approximately 1 cmH2O) LOHP = Low PaO2 (approximately 50 mm Hg) High PEEP (approximately 10 cmH2O) HOLP = High PaO2 (approximately 80 mmHg) Low PEEP (approximately 1 cmH2O) HOHP = High PaO2 (approximately 80 mmHg) High PEEP (approximately 10 cmH2O) MEASUREMENTS AND RESULTS: Hemodynamic and gas exchange data were collected for each experimental condition. CI showed a 13% decline from LOLP (7.0 +/- 1.71/min per m2) to HOHP (6.1 +/- 1.31/min per m2). Both the direct effect of PEEP on the CI (LOLP + HOLP vs LOHP + HOHP, p < 0.01) and the indirect effect related to the improvement in oxygenation (LOLP + LOHP vs HOLP + HOHP, p < 0.01) contributed to the reduction in CI. CONCLUSIONS: In evaluating CI changes induced by PEEP we should take into account the indirect effect of arterial oxygenation upon CI. This should be considered, at least in part, as a physiological adjustment rather than as impaired cardiovascular performance.

Adult↗

Positive end-expiratory pressure prevents the loss of respiratory compliance during low tidal volume ventilation in acute lung injury patients.

STUDY OBJECTIVE: To study the effect of positive end-expiratory pressure (PEEP) on the decay of respiratory system compliance (Cpl,rs) due to low tidal volume (VT) ventilation in acute lung injury (ALI) patients. SETTING: General ICU in a university hospital. PARTICIPANTS: Eight ALI patients with a lung injury score greater than 2.5. INTERVENTION: Pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), with an average VT of 8.5 +/- 0.4 mL/kg, were applied at three levels of PEEP (5, 10, and 15 cm H2O). Before each PCV and VCV period, lung volume history was standardized by manual hyperinflation maneuvers. MEASUREMENTS: We measured Cpl,rs at time 0 (start), 10, 20, and 30 (end) min from the beginning of each PCV and VCV period. Gas exchange and hemodynamic data were collected at end. RESULTS: At PEEP 5 and 10 cm H2O, we observed a progressive Cpl,rs decay with both PCV and VCV modes. At PEEP 5 cm H2O, we detected a higher Cpl,rs decrease during PCV, due to a higher Cpl,rs at start, compared with VCV. At PEEP 15 cm H2O, Cpl,rs did not decrease significantly. Cpl,rs values measured at end as well as oxygenation and hemodynamic data did not differ between PCV and VCV. At PEEP 15 cm H2O, PCV provided lower PaCO2 than VCV. CONCLUSIONS: A PEEP of at least 15 cm H2O was needed to prevent Cpl,rs decay. The progressive Cpl,rs loss we observed at lower PEEP probably reflects alveolar instability.

Adult↗

Small pore size microporous membrane oxygenator reduces plasma leakage during prolonged extracorporeal circulation: a case report.

Plasma leakage has been regarded as the main technical problem during prolonged extracorporeal circulation (ECC) with microporous membrane oxygenators (MMOs). We report the case of a 15 year old male who underwent long term ECC for ARDS and in whom, by using new MMOs with reduced pore size, we were able to achieve prolonged artificial gas exchange efficiency with minimal plasma leakage. We conclude that reduced pore size MMOs might represent a valuable technical advance in extracorporeal oxygenation therapy.

Adolescent↗

A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group.

BACKGROUND: Hemodynamic therapy to raise the cardiac index and oxygen delivery to supranormal may improve outcomes in critically ill patients. We studied whether increasing the cardiac index to a supranormal level (cardiac-index group) or increasing mixed venous oxygen saturation to a normal level (oxygen-saturation group) would decrease morbidity and mortality among critically ill patients, as compared with a control group in which the target was a normal cardiac index. METHODS: A total of 10,726 patients in 56 intensive care units were screened, among whom 762 patients belonging to predefined diagnostic categories with acute physiology scores of 11 or higher were randomly assigned to the three groups (252 to the control group, 253 to the cardiac-index group, and 257 to the oxygen-saturation group). RESULTS: The hemodynamic targets were reached by 94.3 percent of the control group, 44.9 percent of the cardiac-index group, and 66.7 percent of the oxygen-saturation group (P < 0.001). Mortality was 48.4, 48.6, and 52.1 percent, respectively (P = 0.638), up to the time of discharge from the intensive care unit and 62.3, 61.7, and 63.8 percent (P = 0.875) at six months. Among patients who survived, the number of dysfunctional organs and the length of the stay in the intensive care unit were similar in the three groups. No differences in mortality among the three groups were found for any diagnostic category. A subgroup analysis of the patients in whom hemodynamic targets were reached revealed similar mortality rates: 44.8, 40.4, and 39.0 percent, respectively (P = 0.478). CONCLUSIONS: Hemodynamic therapy aimed at achieving supranormal values for the cardiac index or normal values for mixed venous oxygen saturation does not reduce morbidity or mortality among critically ill patients.

Adult↗

Sympathetic modulation of radial artery compliance in congestive heart failure.

Animal studies have suggested that arterial compliance can be modulated by adrenergic influences. Whether this adrenergic modulation also occurs in humans is still a matter of debate. In the present article we address this issue by examining the relationships between sympathetic tone and arterial compliance in a variety of physiological and pathophysiological conditions. We have found that cigarette smoking, ie, an action that produces a marked sympathetic activation, causes a significant reduction in radial artery compliance, as measured by an echotracking device capable of providing continuous beat-to-beat evaluation of this hemodynamic variable. When expressed as compliance index, ie, as the ratio between the area under the compliance-pressure curve and pulse pressure, the reduction amounted to 35.7 +/- 4.8% (mean +/- SEM) and was independent of the smoking-related blood pressure increase. Furthermore, pharmacological stimulation of adrenergic receptors located in the arterial wall was also shown to affect arterial compliance because the radial artery compliance index was markedly reduced (- 29.5 +/- 3.9%) during phenylephrine infusion in the brachial artery at doses devoid of any systemic blood pressure effect. Evidence was also obtained that the relationship between sympathetic activation and arterial compliance has pathophysiological relevance, because in 17 patients with congestive heart failure (New York Heart Association classes II through IV) there was a significant inverse correlation (r = .62, P < .01) between muscle sympathetic nerve activity (directly measured by microneurography in the peroneal nerve) and radial artery compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Alterations of lung and chest wall mechanics in patients with acute lung injury: effects of positive end-expiratory pressure.

In 16 mechanically ventilated patients with acute lung injury (ALI) (eight patients with moderate ALI [moderate group], eight patients with severe ALI [adult respiratory distress syndrome, ARDS group]) and in eight normal anesthetized-paralyzed subjects (control group), we partitioned the total respiratory system mechanics into the lung (L) and chest wall (w) mechanics using the esophageal balloon technique together with the airway occlusion technique during constant flow inflation. We measured lung elastance (Est,L), chest wall elastance (Est,w), and total lung (Rmax, L) and chest wall (Rmax,w) resistance. Rmax,L includes airway (Rmin,L) and "additional" lung resistance (DR,L). DR,L represents the "additional" component due to the viscoelastic phenomena of the lung tissues and time-constant inequalities (pendelluft). Measurements were repeated at 0, 5, and 10 cm H2O of positive end-expiratory pressure (PEEP) in the control group and at 0, 5, 10, and 15 cm H2O PEEP in patients with ALI. The end-expiratory lung volume (EELV) was measured at each level of PEEP. Specific total lung (sRmax,L), airway (sRmin,L), and "additional" lung (sDR,L) resistances were obtained as Rmax,L x EELV, Rmin,L x EELV, and DR,L x EELV, respectively. At PEEP 0 cm H2O, we found that both Est,L (23.7 +/- 5.5 and 13.8 +/- 3.3 versus 9.3 +/- 1.7 cm H2O/L; p < 0.01) and Est,w (13.2 +/- 5.4 and 9.9 +/- 2.1 versus 5.6 +/- 2.3 cm H2O/L; p < 0.01) were markedly increased in patients with ARDS and moderate ALI compared with control subjects, with a significant (p < 0.01) effect of the severity of the disease on Est,L (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Airway Resistance↗

Pergolide mesylate in Parkinson's disease treatment.

In the past 15 years, clinical data of over 1,500 patients treated with pergolide mesylate have been published. Pergolide is a dopamine agonist with a potent stimulating effect on D2 and also on D1 receptors. This pharmacodynamic characteristic seems the most effective in increasing the motility in Parkinson's disease. Pergolide has been used almost exclusively as an adjunct to levodopa treatment. Its positive effects seems to be related to its long plasma half life, about 27 hours, and 5-6 hours of clinical activity; it has shown to be effective on all parkinsonian symptoms except for the reduction of postural reflexes, it reduces off periods and compared to bromocriptine, it considerably improves the activities of daily living. Adverse reactions are, for the most part, mild and reversible, they mostly include nausea and gastroenteric disturbances.

Antiparkinson Agents↗

Lung structure and function in different stages of severe adult respiratory distress syndrome.

OBJECTIVE: To assess the clinical consequences of duration of adult respiratory distress syndrome (ARDS) on lung structure and function. DESIGN: Retrospective analysis. SETTING: A university hospital referral center for extracorporeal support. PATIENTS: A total of 84 patients with severe ARDS (Murray score > 2.5) recruited from 48 intensive care units (1979 to 1992), who suffered ARDS and underwent mechanical ventilation for up to 1 week (37 patients with early ARDS), between 1 and 2 weeks (24 patients with intermediate ARDS), or more than 2 weeks (23 patients with late ARDS) and subsequently underwent extracorporeal support. MAIN OUTCOME MEASURES: Before beginning extracorporeal support, we measured gas exchange, pulmonary mechanics, hemodynamics, oxygen transport and delivery, incidence of barotrauma (presence of one or more thoracic tubes for pneumothorax drainage), and organ dysfunctions. In a subgroup of 16 patients, we studied lung structure by computed tomographic scan, scoring the densities and quantifying the emphysemalike lesions (bullae). RESULTS: Late ARDS showed lower respiratory compliance, higher dead space, higher PaCO2, lower venous admixture, and lower positive end-expiratory pressure requirement compared with early ARDS (P < .01). The incidence of pneumothorax (48.8% of the entire population) was significantly (P < .01) higher in late ARDS (87%) vs intermediate ARDS (46%) and early ARDS (30%). The mortality of patients with pneumothorax (66%) was significantly (P < .01) higher compared with patients without pneumothorax (46%). The number of bullae per lung was significantly higher in late ARDS vs intermediate and early ARDS (mean [SD], 8 [4], 4.3 [5], and 1.9 [3.9], respectively; P < .01), and they were preferentially distributed in the dependent lung regions. The number of bullae per lung was significantly higher in patients with pneumothorax vs those without pneumothorax (mean [SD], 13.6 [9.8] vs 1.4 [2.1]; P = .007). The mean (SD) duration of ARDS in patients with pneumothorax was 15.3 (10.0) days vs 7.0 (6.6) days in those without pneumothorax (P = .0001). No differences within the three groups were found in computed tomographic scan densities, hemodynamics, and number of organ system dysfunctions. CONCLUSIONS: The lung structure and function changes markedly with ARDS duration, and the late stages may be described as restrictive lung disease with superimposed emphysemalike lesions. Presence of pneumothorax affects survival and appears to be related to the lung structural changes occurring with time.

Adolescent↗

Vertical gradient of regional lung inflation in adult respiratory distress syndrome.

We obtained chest computed tomography (CT) sections in 12 normal subjects (controls) and 17 patients with the adult respiratory distress syndrome (ARDS) to investigate regional lung inflation. A basal CT section (just above the diaphragm) was obtained in the supine position at zero cm H2O end-expiratory pressure. In each CT section the distance from ventral to dorsal surface (hT) was divided into 10 equal intervals, and 10 lung levels from ventral (no. 1) to dorsal (no. 10) were defined. Knowing the average density and the volume of each level, we computed: (1) the tissue volume; (2) the gas/tissue (g/t) ratio (index of regional inflation); (3) the hydrostatic pressure superimposed on each level (SPL), estimated as density x height. The total volume of the basal CT section was 49 +/- 2.5 ml x m-2 (mean +/- SE) in control subjects and 43 +/- 2.3 ml x m-2 in patients with ARDS (p = not significant [NS]). The tissue volume, however, was 16.7 +/- 0.8 ml x m-2 in control subjects and 31.6 +/- 1.7 ml x m-2 in patients with ARDS (p < 0.01). The g/t ratio in level 1 averaged 4.7 +/- 0.5 in control subjects and 1.2 +/- 0.2 in patients with ARDS (p < 0.01), and this ratio decreased exponentially from level 1 to level 10, both in controls and patients with ARDS. The Kd constant of the exponential decrease was 13.9 +/- 1.3 cm in control subjects and 7.8 +/- 0.8 cm in patients with ARDS (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome.

OBJECTIVE: To test the hypothesis that positive end-expiratory pressure (PEEP) prevents the collapse of a given lung region when it is equal to or greater than the hydrostatic pressure superimposed (SPL) to that region. DESIGN: Intervention study with sequential levels of PEEP applied in random order to a cohort of patients with adult respiratory distress syndrome (ARDS). SETTING: Referral center for ARDS in a university hospital. PATIENTS: Ten ARDS patients (with Murray scores > 2.5). INTERVENTION: Basal computed tomographic (CT) section taken at 0, 2, 4, 5, 6, 8, 10, 12, 14, 15, and 20 cm H2O PEEP. MAIN OUTCOME MEASURES: Basal lung CT sections were divided into 10 equal levels from the ventral to dorsal surfaces. In each level SPL was measured from density and height. The inflation of the level was measured as the gas/tissue ratio (g/t); g/t changes with PEEP were defined as the g/t-P curve. The slope of the g/t-P curve was defined as level compliance (ie, the ratio of change in the g/t of the level to the change in pressure). A linear g/t-P curve was the criterion to detect inflation without recruitment (ie, new pulmonary units opening at a given pressure). A biphasic g/t-P curve (change of compliance after an inflection point) was the criterion to detect recruitment. Pflex was defined as the pressure at which the inflection point occurred. RESULTS: The SPL increased from level 1 (ventral) to level 10 (dorsal) (r = .91; P < .01). The number of linear g/t-P curves decreased from level 1 to level 10 (r = .98; P < .01), while the number of biphasic g/t-P curves increased (r = .95; P < .01). The Pflex increased from level 1 to 10 (r = .97; P < .01) and Pflex was similar to SPL (Pflex = 1.05 + 0.9 SPL; r = .75; P < .01). CONCLUSIONS: The increased SPL causes compression atelectasis; this is prevented when PEEP to a given lung region is equal to or greater than the SPL.

Adolescent↗

Respiratory mechanics and bronchodilator responsiveness in patients with the adult respiratory distress syndrome.

OBJECTIVE: To study the effects of salbutamol (a selective beta 2-adrenergic receptor agonist) on respiratory mechanics in patients with the adult respiratory distress syndrome (ARDS). DESIGN: Prospective study. SETTING: ICU in a university hospital. PATIENTS: Seven mechanically ventilated, paralyzed ARDS patients. MAIN OUTCOME MEASUREMENTS: Measurements of respiratory system compliance, maximum, and minimum inspiratory resistance (by the end-inspiratory occlusion method during constant flow inflation) were performed at 0, 5, 10 cm H2O positive end-expiratory pressure, both before and at least 30 mins after the start of a continuous iv infusion of salbutamol (15 micrograms/min). Minimum inspiratory resistance represents the ohmic air flow resistance, while maximum inspiratory resistance includes minimum inspiratory resistance plus the effective additional resistance due to stress adaptation and to time constant inhomogeneities. Air flow was measured at the airway connector and tracheal pressure near the central end of the artificial airway. RESULTS: Maximum inspiratory resistance, minimum inspiratory resistance, and additional resistance were higher than the values reported for normal anesthetized subjects. On average, salbutamol caused a decrease in maximum and minimum inspiratory resistances (from 6.48 +/- 2.56 to 4.67 +/- 1.74 and from 4.06 +/- 2.12 to 2.07 +/- 0.95 cm H2O/L/sec, respectively). Positive end-expiratory pressure increased additional resistance, whereas it decreased minimum inspiratory resistance. No interaction was found between positive end-expiratory pressure and salbutamol. Respiratory system compliance was not significantly affected by salbutamol nor by positive end-expiratory pressure. CONCLUSIONS: In ARDS patients, salbutamol decreases the abnormally high airway resistance, by reducing minimum resistance, but has no effect on the effective additional resistance.

Adolescent↗