Breath of the Sith: a case study on respiratory failure in a galaxy far, far away


Excerpt from a Physiology News feature by Ronan Berg, Department of Clinical Physiology & Nuclear Medicine, Frederiksberg and Bispebjerg Hospitals & Ronni Plovsing, Department of Intensive Care 4131, University Hospital Rigshospitalet, both in Copenhagen, Denmark.

While the latest instalments in the Star Wars saga have thrilled physiologists and non-physiologists alike, it may be worthwhile to take a look back at what we as respiratory physiologists have learned from the venerated space opera so far. It remains indisputable – at least between the authors of this paper – that the first six episodes’ protagonist-turned-villain-turned-saviour Anakin Skywalker/Darth Vader is the most fascinating case study on respiratory failure in the history of cinema. […]

Health hazards of volcanic fumes

Figure 1. An advanced bi-level positive airway pressure system integrated in a whole-body armoured suit for the treatment of acute and chronic respiratory failure in a Sith Lord. © LucasArts

In the Star Wars saga, the highly talented Jedi knight, Anakin Skywalker, choses to abandon the monastic Jedi Order and instead join his father figure Sheev Palpatine in the more exclusive and politically involved Sith Order. As he does this, he assumes a new identity as Darth Vader, and earns the title Dark Lord of the Sith. For a number of reasons, this change of careers does not impress a former Jedi Master of his, and the two soon clash in a light sabre duel on the volcanic planet Mustafar. The confrontation results in a near-fatal outcome for Darth Vader who loses several limbs in the fight, and while he is incapacitated on the volcanic shore, he furthermore suffers inhalational injury and third degree burns. However, before he passes away, Palpatine comes to the rescue, and organises timely medical intervention. […] After the incident, Darth Vader is unable to breathe freely at all; outside his personal meditation  chamber, which also appears to function as some kind of a fancy hyperbaric oxygen facility, he continually relies on a mobile life-support system, which is integrated in a whole-body armoured suit, in order to survive (Figure 1).

Darth Vader’s acute respiratory failure appears to be the consequence of a number of factors, including direct thermal injury to the airways, chemical damage to the lung parenchyma caused by inhalation of smoke and volcanic dust particles, carbon monoxide poisoning, as well as secondary effects to his severe third degree burns, which seems to cover ~100 % of his total body surface area. […]

Due to his quite severe facial burns, it is difficult to determine whether Darth Vader exhibits ‘cherry-red cheeks’ at this stage, a typical clinical finding associated with carbon monoxide poisoning.

Inhalation-induced acute respiratory distress syndrome in a Sith Lord

Darth Vader’s immediate respiratory distress on the volcanic shore is probably caused by volcanic gaseous irritants with high water solubility in the volcanic fumes, which cause immediate symptoms of tracheobronchitis, and impair pulmonary gas exchange (Nemery 2006; Mlcak et al., 2007). Since Darth Vader may concurrently be exposed to high levels of carbon monoxide, which both impairs the red blood cell uptake of oxygen in the lungs due to its higher affinity for haemoglobin than oxygen, and furthermore shifts the oxygenhaemoglobin saturation curve to the left, so that the release of oxygen from the red blood cells to tissue mitochondria (and perhaps also the conceivably similar midi-chlorians) in various organs is impaired; severe tissue hypoxia therefore ensues. Due to his quite severe facial burns, it is difficult to determine whether Darth Vader exhibits ‘cherry-red cheeks’ at this stage, a typical clinical finding associated with carbon monoxide poisoning, but his rather agitated emotional state is characteristic of the cerebral dysfunction often encountered in this clinical condition.

We deem it irrefutable that Darth Vader fulfils the diagnostic criteria for acute respiratory distress syndrome within a few hours after the incident on Mustafar.

Within a few hours, that is, after Darth Vader has been evacuated by Palpatine, the effects of direct thermal injury on the central parts of the lungs, as well as the effects of the volcanic water soluble gaseous irritants and aerosols set in. These give rise to acute chemical pneumonitis with non-cardiogenic pulmonary oedema and induce a reduction in ventilatory capacity with increased pulmonary ventilation-perfusion inequality, thus severely impairing pulmonary gas exchange (Nemery 2006). At this stage, the systemic inflammatory response to the severe skin burns may furthermore disseminate from the blood stream to the alveolar compartment, and thus exaggerate the pulmonary inflammatory response. Although appropriate diagnostic imaging would be required to establish the diagnosis here on Earth, we deem it irrefutable that Darth Vader fulfils the diagnostic criteria for acute respiratory distress syndrome within a few hours after the incident on Mustafar, which is a common complication both after inhalation injury and severe skin burns (Mlcak et al., 2007).

Figure 2. Respiratory rate according to activity level in a Sith Lord (n =1). Data are obtained from Plovsing & Berg (2014) and presented as mean (± standard deviation). ‘Rest’ includes recreational activities in a meditation chamber; ‘Normal everyday activities’ include various friendly encounters as well as torture of enemies, colleagues, and employees; ‘Stressful situations’ includes increased alertness and arousal; ‘Exercise’ includes running, combat and light sabre duels.

Following extensive robotic surgery, the medical droids choose to treat Darth Vader’s respiratory condition by means of the iconic whole-body armoured suit. The suit contains a mobile life-support system, and from a careful analysis of Episodes IV-VI, we have concluded that it functions as an advanced bi-level positive airway pressure (BPAP) system that supports Darth Vader’s intrinsic breathing both during in- and expiration, while preventing airway collapse, and continually supplying him with oxygen (Plovsing & Berg 2014). Accordingly, his respiratory rate varies with his activity level (Figure 2), and pressure equalisation with the surroundings can clearly be heard when his helmet is detached. Other scientists have noted that Darth Vader’s whole-body armoured suit may furthermore function as a means of preventing infections, which is notably relevant in the immediate aftermath of the events on Mustafar, due to Darth Vader’s extensive skin burns (Perrella et al., 2015).

Read the full article in Physiology News.

References:

Mlcak RP, Suman OE, Herndon DN (2007). Respiratory management of inhalation injury. Burns 33, 2-13

Nemery B (2006). Chemical-induced lung injury and its long-term sequelae. In: Imaging of Occupational and Environmental Disorders of the Chest. Springer Berlin Heidelberg, pp. 67-75.

Perrella A, Russo C, Giuliani A, Esposito C, Saturnino P (2015). Infection control in a far, far away Galaxy: new and alternative learning tool from popular culture to improve the antimicrobial stewardship. North Am J Med Sci 7, 236-7

Plovsing RR, Berg RMG (2014). Pulmonary pathophysiology in another galaxy. Anesthesiology 120, 230-2

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