Total Respiratory System Resistance Research Articles

Tracheal stenting improves airway mechanics in infants with tracheobronchomalacia

The compliance and expiratory resistance of the tracheobronchial tree is increased in infants with tracheobronchomalacia because of a weakness in cartilaginous support of the airway. Life threatening episodes may occur in these patients due to airway collapse. The goals of this study were to compare the effects on respiratory system mechanics of stenting the airway with either continuous positive airway pressure (CPAP) or a long tracheostomy tube. Five infants were studied: two had bronchopulmonary dysplasia (BPD), 2 had associated congenital anomalies, and one had tracheomalacia and polydactyly; none had a tracheoesophageal fistula. All patients required tracheostomy and were treated with CPAP. Lung mechanics were evaluated by measuring transpulmonary pressure, obtained by subtracting airway opening pressure from pleural pressure measured with an esophageal balloon, and flow measured with a pneumotachometer placed in series with the tracheostomy. Dynamic compliance (Cdyn) and total respiratory system resistance (Rt) were calculated by two-factor, least-mean-squares analysis, solving for the equation of motion of the lung with the PeDS system (MAS, Hatfield). In all subjects Cdyn increased and Rt decreased with increasing CPAP. In 4 subjects the airway was stented with a specially designed, long tracheostomy tube which reached to just above the carina; the special tube improved dynamic mechanics sufficiently to permit the discontinuation of CPAP. Speech was improved by fenestrating the tube and the use of a one-way inspiratory valve, placed over the tracheostomy. Inspiration occurred via the tracheostomy and expiration was directed to the larynx.

291 RESPIRATORY MECHANICHS IN INFANTS WITH ACUTE BRONCHIOLITIS

Objective: to determine alterations in pulmonary function tests in infants in acute phase of bronchiolitis. Subjects and methods: Partial forced expiratory flow-volume curves obtained by an inflatable jacket and end-inspiratory single occlusion test were used to determine maximal flow at Functional Residual Capacity (VmaxFRC) and total respiratory system compliance and resistance (Crs, Rrs) in 54 previously healthy infants in acute phase of bronchiolitis and in 44 healthy control infants aged 1-12 months. PEDS and PUFF systems (Medical Associates, Hatfield, Pa, USA) were used for these measurements. Results: see table. Table: age (yr); Length (cm); VmaxFRC (mL/s). (mL/cmH2O). Rrs (cmH2O/Ls). % Predicted by Tepper et al. Am Rev Respir Dis 1986;134:513-9. Mean (standard deviation). Comparision by t test for independent samples. NS: no significative. Conclusion: Important decrease in VmaxRFC and compliance with no significant increase in resistance characterizes acute phase of bronchiolitis.

124 FLOW DEPENDENCE OF RESPIRATORY MECHANICS IN MECHANICALLY VENTILATED NEONATES

To investigate the effects of inspiratory flow and/or inspiratory time on the different components of respiratory mechanics, 15 mechanically ventilated neonates for respiratory failure, were studied (gestational age : 26 to 40 weeks; birth weight : 750 to 5900 gm). All neonates were ventilated during volume controlled ventilation with a Servo 900C Siemens ventilator. Dynamic and static elasticity (Edyn,rs and Est,rs), airway and tissue resistance (Raw and Rvis,rs) ^ intrinsic positive-end-expiratory pressure (PEEPi) were calculated by using interrupter technique (1) at various inspiratory times (20, 25, 33, 50 and 67 per cent of the respiratory cycle), without changing of the tidal volume and the respiratory rate. Raw increased whereas Rvisc,rs decreased with increasing flow, provoking decreasing of total respiratory system resistance (Rtot,rs = Raw + Rvisc,rs). Rvisc,rs represented an important part of Rtot,rs (40 - 70% as a function of flow). Est,rs remained constant but Edyn,rs increased with ncreasing flow. Time constant of the respiratory system decreased with decreasing inspiratory time below 0.65 seconds. It could traduct an adaptatation of respiratory mechanics with inspiratory time variations to maintain tidal volume constant. These results demonstrate that the respiratory mechanics are flow and/or time dependent in mechanically ventilated newborn infants. This dependence is mainly related to viscoelastic properties of the respiratory system and should be considered to optimize ventilator settings. (1) Similowski T et al. J.Appl.Physiol. 1989;67:2219-2229.

Functional residual capacity and total respiratory system impedance in wheezing infants.

Airways obstruction has been demonstrated in acutely wheezing infants. The aim of the present study was to assess functional abnormalities as detected by measurement of total respiratory system resistance (Rrs) and functional residual capacity (FRC) in infants with a history of recurrent episodes of wheezing, while not acutely ill. In 30 such infants (mean age, 10 months; range, 4-17) and in 10 healthy infants (mean age, 6 months; range, 0-14) four Rrs measurements, performed with the forced pseudo-random noise (PRN) oscillation technique, and three FRC determinations, using the closed-circuit helium dilution technique, were averaged. A lower than predicted FRC was demonstrated in 20/30 (66%) patients. At 16 Hz, Rrs was significantly above predicted in 3/30 (10%) patients. Specific Rrs (Rrs x FRC) at 16 Hz was increased in 5/30 (17%) patients. In conclusion, the PRN oscillation technique combined with FRC measurement by helium dilution detects lung function abnormalities in a minority of wheezing infants during symptom-free intervals.

Respiratory Mechanics by the Passive Relaxation Technique in Conscious Healthy Adults and Patients With Restrictive Respiratory Disorders

The passive relaxation single-breath technique has been used primarily in anesthetized human subjects to measure total respiratory system elastance and resistance. This method was used to assess the pressure-flow characteristics in 32 relaxed, conscious patients with restrictive respiratory disorders (20 with neuromuscular disease, 12 with sarcoidosis) and 27 similarly aged control subjects free of cardiothoracic disease. Using Rohrer's pressure-flow relationship during passive expiration, P/V = K1 + K2V, considerable curvilinear pressure-flow characteristics were found in both groups. These can be attributed to a combination of the upper airway and viscoelastic and elastoplastic behavior of the respiratory system. Despite the greater elastic recoil pressure (and respiratory elastance) of the restrictive patients, their pressure-flow characteristics were similar to those of the control subjects. These findings imply structural similarities in at least the lower airways, or in the effects of retractile forces along airways compensating for reduced lung volumes.

Quantification of nasal involvement in a guinea pig plethysmograph.

We have developed a technique for measuring lung function in conscious guinea pigs using a whole body plethysmograph. Because guinea pigs breathe through the nose, a technique was also developed to measure nasal and lower respiratory system conductance simultaneously in anesthetized animals. The upper and the lower airways could be challenged separately and studied in a manner similar to the conditions in the plethysmograph. Aerosols of histamine, carbachol, or ovalbumin delivered to the nose in sensitized animals had no effect on nasal conductance, even in doses 100 times higher than that required to reduce lower respiratory system conductance. However, intravenous histamine increased nasal conductance. Thus, although nasal resistance constitutes the majority of the total respiratory system resistance measured in the plethysmograph, nasal resistance is unaffected by the aerosol drugs studied. We therefore consider changes in resistance measured in the plethysmograph to originate at or below the larynx. The plethysmographic technique described here is a reliable, reproducible, and rapid technique that enables repeated measurement in animals and minimizes animal trauma.

Comparison of Airway Resistance and Total Respiratory System Resistance in Infants

Airway resistance (Raw) can be measured throughout the respiratory cycle by whole body plethysmography. Total resistance of the respiratory system (Rrs) can be measured from the relaxed expiration that follows end inspiratory occlusion. The purpose of this study was to compare the two methods in normal infants and in infants with airway obstruction of different types and severity. Fifteen infants with essentially normal lungs aged 24.6 +/- 18.0 (SD) wk, nine infants with congenital stridor aged 36.0 +/- 17.3 wk, and eleven wheezy infants aged 20.1 +/- 11.3 wk had simultaneous measurements of Raw and Rrs. Rrs was similar to Raw both during inspiration and expiration in the normal infants, to all expiratory Raw in those with congenital stridor, and to all inspiratory and early expiratory Raw in the wheezy infants. Raw was markedly and significantly higher than Rrs during mid and late inspiration in infants with congenital stridor and during late expiration in the wheezy infants. We conclude that Rrs is a good estimate of Raw in normal infants and of early expiratory Raw in all infants. In infants with airway obstruction, Rrs does not reveal the dynamic changes in Raw during tidal breathing, nor can it differentiate between infants with upper and lower airway obstruction.

Hyperoxia-induced Airway Remodeling in Immature Rats: Correlation with Airway Responsiveness

We recently found that exposure of 21-day-old rats to hyperoxia (> 95% O2 for 8 days) significantly increased in vivo airway cholinergic responsiveness and that O2 exposure also increased airway epithelial and smooth muscle layer thicknesses in a separate cohort of animals. There was substantial variation in the magnitude of both the functional and structural responses to hyperoxia. The present study was designed to test whether the magnitude of O2-induced airway remodeling could account for individual differences in airway responsiveness after O2 exposure, as well as for the difference in responsiveness between air- and O2-exposed animals. We assessed in vivo airway responsiveness to aerosolized acetylcholine (ACh) and airway architecture in 14 O2- and 5 air-exposed, immature rats. Total respiratory system resistance was determined using a plethysmographic method. The mean thicknesses and fractional areas of the airway epithelial and smooth muscle layers were determined by contour tracing using a digitizing pad and microcomputer. Both the small (circumference < 1,000 microns) and central (circumference 1,000 to 4,000 microns) airways were studied. For O2-exposed rats, individual values of EC200 ACh correlated negatively with small airway smooth muscle layer thickness (r = -0.59, p < 0.05; ANOVA), small airway smooth muscle layer fractional area (r = -0.75, p < 0.01), small airway epithelial thickness (r = -0.54, p < 0.05), small airway epithelial fractional area (r = -0.69, p < 0.01), and central airway smooth muscle layer thickness (r = -0.53, p < 0.05). When both air- and O2-exposed animals were considered, EC200 ACh correlated negatively with all eight parameters of airway layer thickness and fractional area.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of PEEP on the mechanics of the respiratory system in ARDS patients.

In patients with adult respiratory distress syndrome (ARDS) we studied the effect of positive end-expiratory pressure (PEEP) on respiratory mechanics. We used the technique of rapid airway occlusion during constant flow (V) inflation to partition the total respiratory system resistance (Rrs) into the interrupter resistance (Rint,rs) and the additional resistance (delta Rrs) due to viscoelastic pressure dissipations and time constant inequalities. We also measured static (Est,rs) and dynamic (Edyn,rs) elastance of the respiratory system. The procedure was carried out in nine ARDS patients at different inspiratory V and inflation volumes (delta V) at PEEP of 0, 5, 10, and 15 cmH2O. We found that during baseline ventilation (delta V = 0.7 liter and V = 1 l/s), Est,rs, Edyn,rs, and Rint,rs did not change significantly with PEEP, whereas delta Rrs and Rrs increased significantly only with PEEP of 15 cmH2O. The increase of delta Rrs and Rrs with PEEP was positively correlated with the concomitant changes in end-expiratory lung volume (P < 0.001). At all levels of PEEP, under iso-delta V conditions, delta Rrs decreased with increasing V, whereas at a fixed V, delta Rrs increased with increasing delta V. A four-parameter model of the respiratory system failed to fully describe respiratory dynamics in the ARDS patients, probably due to nonlinearities.

Maneuver-Free Determination of Compliance and Resistance in Ventilated ARDS Patients

At present, most methods of lung mechanics analysis do not take nonlinearities of compliance and resistance into account. Nevertheless, nonlinearity of compliance is an inherent property of the respiratory system in ARDS and nonlinearity of resistance is an inherent property of the endotracheal tube. Herein we describe a computer-assisted multipoint method (LOOP) for breath-by-breath calculation of total respiratory system compliance (Ctrs) and total respiratory system resistance (Rtrs). Unlike our previously published method, LOOP excludes nonlinearities of compliance and resistance by confining the data used from the P/V/V loop to sequences with constant flow in inspiration and with steadily decreasing flow in expiration. LOOP was applied to five patients ventilated after open heart surgery (HEART group) and 12 patients ventilated for ARDS (ARDS group). The compliance results from LOOP were compared with the semistatic reference values corrected for intrinsic PEEP (CsST,IP). In the ARDS patients the compliance values from LOOP (46 ml/mbar) corresponded well with the semistatic compliance (CsST,IP = 42 ml/mbar). Despite the fact that there is no reference method for resistance known to date, we also determined the semistatic resistance (RsST) at end-inspiratory pause. The resistance values determined with LOOP were 8.5 mbar/L/s (RsST = 7.3 mbar/L/s) in the HEART group and 11.1 mbar/L/s (RsST = 8.6 mbar/L/s) in the ARDS group. LOOP gives a good correspondence between the linear RC model and the measured data in ARDS patients. In conclusion, LOOP requires neither an end-inspiratory pause (EIP) nor additional determination of intrinsic PEEP and gives Ctrs, automatically corrected for IPEEP, as well as Rtrs breath by breath at the bedside.

Evaluation of nasal impedance using the forced oscillation technique in infants

By applying oscillations to the respiratory system through a rigid face mask, the infant-adapted Lándsér forced oscillation technique measures impedance of the total respiratory system including the nose, at frequencies from 4 to 52 Hz. The present study was aimed at evaluating nasal impedance in infants from consecutive forced oscillation measurements through both nostrils and each nostril separately, using a simple electrical model. In 30 asthmatic infants with varying degrees of nasal obstruction, aged 1-16 months, calculated nasal resistance (Rn) at 24 Hz ranged from 1 to 16 cm H2O.L-1.s. The ratio of Rn to total respiratory system resistance varied between 1 and 48% (mean: 16%). In seven non-asthmatic infants, aged 0-12 months, Rn was between 1 and 11 cm H2O.L-1.s. Nasal patency (evaluated clinically) was correlated with the calculated Rn (P less than 0.05). Rn showed almost no frequency dependence between 24 and 48 Hz as demonstrated by a mean slope of -0.09 +/- 0.08 cm H2O.s2/L for the asthmatic and of -0.08 +/- 0.07 for the non-asthmatic infants. In seven of the asthmatic infants the differences between two Rn determinations at a 45 min interval ranged from -1.7 to 3.8 cm H2O.L-1.s-1 at 24 Hz and from -3.6 to 1.0 at 48 Hz. Changes in Rn did not correlate with changes in total respiratory system resistance (P greater than 0.05). In conclusion, nasal impedance can be approximated from three consecutive measurements through both nostrils and through each nostril separately.

Effects of a clinically detectable PDA on pulmonary mechanics measures in VLBW infants with RDS

We examined the effect of a clinically detectable patent ductus arteriosus (PDA) and its successful treatment with indomethacin on serial measures of pulmonary mechanics in 10 very-low-birthweight (VLBW) intubated infants with respiratory distress syndrome (RDS). Pulmonary mechanics were measured by the passive expiratory flow technique. Total respiratory system compliance (Crs) gradually improved as RDS resolved. However, a significant decrease in mean Crs was associated with the development of a clinically detectable PDA, ranging from 1.51 +/- 0.21 to 0.90 +/- 0.08 mL/cmH2O/m (P less than 0.05). We also noted an increase in mean Crs, from 0.90 +/- 0.08 to 1.49 +/- 0.21 mL/cmH2O/m (P less than 0.05), after successful treatment of a PDA with indomethacin. Total respiratory system resistance (Rrs) did not change. We conclude that a clinically significant PDA is associated with a decreased Crs and that successful treatment of a PDA with indomethacin is associated with an improvement in lung compliance. These findings imply that the development of a clinically detectable PDA and its subsequent treatment complicates the interpretation of pulmonary mechanics data in VLBW infants with RDS.

Correspondence between forced oscillation and body plethysmography during bronchoprovocation with carbachol in children

We compared dose-response curves obtained with the forced oscillation technique (FOT) and with body plethysmography during bronchoprovocation in children. In 40 stable asthmatic children (age, 5-16 yr) we performed challenges with doubling concentrations of inhaled carbachol (0.15-10 mg/mL) until specific airway resistance SRaw had increased by 100% (PC100SRaw). The FOT-response was assessed by total respiratory system resistance (Rrs, cmH2O.1(-1).s) and reactance (Xrs, cmH2O.1(-1).s) from 8 to 26 Hz, expressed as mean Rrs (Rrs), mean Xrs (Xrs), Rrs at 8 Hz (Rrs8), and mean slope of Rrs (dRrs/df). Dose-response curves were analyzed for threshold concentrations (TC) causing a 3 SD change from baseline and sensitivity indices (SI) defined as differences between baseline and postchallenge values (at PC100SRaw) divided by baseline SD. Median TC of Rrs8, Rrs, Xrs, dRrs/df, and SRaw was 0.21, 0.30, 0.34, 0.41, and 0.42 mg/mL, respectively, indicating a slightly higher sensitivity for FOT. Median SI values of SRaw and Xrs (12.0 and 8.2; difference n.s.) were significantly higher than those of the other parameters. Multiple regression analysis revealed only the absolute change of Xrs (delta Xrs), baseline Rrs and age as significantly (P less than 0.001) correlated with the percentage change of SRaw (delta %SRaw). Best correlation (r = 0.86) with delta %SRaw was found for the function: FOT score = -102.5 X delta Xrs X exp(-0.196 X Rrs + 0.038 X age). Provocative concentrations estimated by this FOT score differed from PC100SRaw by less than one (two) concentration steps in 34 (40) out of 40 children.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurements of pulmonary mechanics prior to the elective extubation of neonates

We measured total respiratory system compliance (CRS) and resistance (RRS) by the passive expiratory flow technique prior to the elective extubation of 61 neonates with a history of respiratory distress syndrome. Successful trials of extubation were characterized by a higher mean value of CRS when compared to trials that led to reintubation (1.52 vs. 1.10 mL/cm H2O, P = 0.004). Low values of CRS (0.9 mL/cm H2O or less) were invariably associated with extubation failure, whereas high values of CRS (1.3 mL/cm H2O or greater) were associated with extubation success in 94% of patients. A higher mean value of RRS was recorded in the group of infants who failed extubation when compared to those who were successful (0.22 vs. 0.17 cm H2O/mL/s, P = 0.042). We propose that measurements of pulmonary mechanics, particularly CRS, may be useful in identifying infants who will be at risk for extubation failure.

Evoked bronchoconstriction: testing three methods for measuring respiratory mechanics

In order to assess the usefulness of methods for noninvasive study of respiratory mechanics in intubated patients better, we studied 16 anesthetized paralyzed mechanically ventilated guinea pigs previously sensitized with ovalbumin. Respiratory system elastance and resistance were determined in control and acute antigen exposed (AAE) animals by the end-inflation occlusion method (EIOM), the single-breath method (SBM), and the interrupter technique (IT). In control group, total respiratory system resistance and elastance were constant over tidal volume range and the three methods provided similar results. In AAE group elastance was also constant throughout tidal volume and measured by SBM and IT was, respectively, 93.4 and 57.9% higher than in control group. The relationships between resistive pressure and expiratory flow became curvilinear with an upward convexity. IT underestimated both elastance and resistance measurements in AAE group. Using EIOM the determination of the homogeneous and uneven components of respiratory resistance was possible in control animals, whereas in AAE group resistance was entirely represented by its uneven component.

Interrupter technique for measurement of respiratory mechanics in anesthetized humans.

Flow (V), volume (V), and tracheal pressure (Ptr) were measured throughout a series of brief (100 ms) interruptions of expiratory V in six patients during anesthesia (halothane-N2O) and anesthesia-paralysis (succinylcholine). For the latter part of spontaneous expiration and throughout passive deflation during muscle paralysis, a plateau in postinterruption Ptr was observed, indicating respiratory muscle relaxation. Under these conditions, passive elastance of the total respiratory system (Ers) was determined as the plateau in postinterruption Ptr divided by the corresponding V. The pressure-flow relationship of the total system was determined by plotting the plateau in Ptr during interruption against the immediately preceding V. Ers averaged 23.5 +/- 1.9 (SD) cmH2O X l-1 during anesthesia and 25.5 +/- 5.4 cmH2O X l-1 during anesthesia-paralysis. Corresponding values of total respiratory system resistance were 2.0 +/- 0.8 and 1.9 +/- 0.6 cmH2O X l-1 X s, respectively. Respiratory mechanics determined during anesthesia paralysis using the single-breath method (W.A. Zin, L. D. Pengelly, and J. Milic-Emili, J. Appl. Physiol. 52: 1266-1271, 1982) were also similar. Early in spontaneous expiration, however, Ptr increased progressively during the period of interruption, reflecting the presence of gradually decreasing antagonistic (postinspiratory) pressure of the inspiratory muscles. In conclusion, the interrupter technique allows for simultaneous determination of the passive elastic as well as flow-resistive properties of the total respiratory system. The presence of a plateau in postinterruption Ptr may be employed as a useful and simple criterion to confirm the presence of respiratory muscle relaxation.

Single-breath measurement of lung mechanics in very low birth weight infants.

The expiratory time constant of the respiratory system (Trs) and the total respiratory system compliance (Crs) were measured from the analysis of a flow-volume loop during relaxed expiration, and the total respiratory system resistance (Rrs) was derived from the relationship: Rrs = Trs/Crs. In ten intubated and mechanically ventilated very low birth weight infants, the values obtained for compliance (0.21 to 0.71 ml/cm H2O) were similar to those found using an occlusion technique during spontaneous breathing. The values of Trs were 0.03 to 0.14 sec. These Trs values were altered by adding known resistive loads. The corresponding derived values for Rrs were close to the values of the added resistance loads, suggesting that resistance values found in this group of ventilated babies (120 to 380 cm H2O/L X sec) were accurate.

Respiratory response to sulfuric acid and sulfate salts mist

In order to investigate the effects of sulfuric acid and sulfate salts mist on the respiratory system, guinea pigs were exposed to acute conditions of sulfuric acid, ammonium bisulfate, ammonium sulfate, sodium bisulfate, sodium sulfate of 50mg-SO4/m3, respectively. Animals developed laboured breathing, only when exposed to acidic mist. Furthermore, it was shown that laboured breathing might be related to the acidity of mist. No significant differences in respiratory frequency (f), total respiratory system resistance (T. R. S. R) and pseudo-flow rate (Vpse) were observed between ammonium bisulfate (acidic) exposed group and ammonium sulfate (neutralized salt) exposed group, before laboured breathing development. Histamine content of lung and tracheal tissues were also examined. Tracheal histamine level of ammonium salts exposed group was reduced compared to the control group, but the relationship between laboured breathing development and histamine content was not observed.

Ovalbumin-induced lung disease in the pony: role of vagal mechanisms.

In awake sensitized ponies, we studied the effect of aerosol ovalbumin challenge on ventilation, pulmonary mechanics, lung volume, and gas exchange before and after vagal blockade. We also challenged the left lung and measured respiratory rate (f) and right and left respiratory system resistance (RrsR, RrsL) before and after both left and bilateral vagal section. Bilateral ovalbumin aerosol challenge increased f, minute ventilation (VE), total respiratory system resistance (Rrs), and minimal volume, decreased dynamic compliance, total lung capacity, and arterial oxygen tension, and was without effect on tidal volume (VT), functional residual capacity, quasi-static lung compliance, and arterial carbon dioxide tension. Vagal blockade reversed the increase in f, VE, and Rrs and increased VT. Challenge of the left lung increased f and RrsL but did not alter RrsR. Bilateral vagal section reversed the tachypnea but unilateral section did not. Histopathologic lesions included acute fibrinopurulent obstructive bronchiolitis, bronchitis, edema, and alveolar distension. We conclude that local mechanisms are of critical importance in the pathogenesis of ovalbumin-induced airway obstruction in ponies, that increased sensitivity of airway smooth muscle to normal vagal tone may also play a role, and that tachypnea following challenge is caused by activity of pulmonary receptors with vagal afferent fibers.

Influence of human vocal cord movements on airflow and resistance during eupnea.

The pattern of respiratory movements of the vocal cords in relation to airflow and respiratory system resistance was assessed in healthy human volunteers during quiet breathing. Motion pictures of the vocal cords were obtained through a fiber-optic laryngoscope inserted transnasally under topical anesthesia. A simultaneous estimate of lung volume was obtained using either rib cage and abdominal magnetometer coils or an integrated pneumotachograph signal. The vocal cords separated during inspiration and moved closer together during the expiratory phase of each breath. The extent of these movements varied greatly among the subjects. Total respiratory system resistance, assessed by the forced oscillation technique, was negatively correlated with distance between the vocal cords when measured at isoflow points in inspiration and expiration. Analysis of breath-by-breath variations in expiratory airflow and vocal cord position revealed that decreases in airflow accompanied decreases in the distance between the vocal cords. The results of this study indicate that the human larynx participates in the regulation of respiratory airflow by providing a variable, controlled resistance.