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Respiratory Mechanics Derived From Signals in the Ventilator Circuit

Umberto Lucangelo MD, Francesca Bernabe MD, and Llus Blanch MD PhD

Introduction
Equation of Motion
Dynamic Mechanics
Time Course of Airway Pressure During Constant-Flow Inflation
Static Mechanics
Pressure-Volume and Flow-Volume Loops
Summary

The aim of this article is to identify and interpret the data provided by modern ventilators that
provide the greatest clinical help in evaluating respiratory mechanics during mechanical ventila-
tion. In intensive care, respiratory mechanics can be assessed in dynamic conditions (no flow-
interruption) or static conditions (occlusion techniques) to record compliance and resistance and to
monitor pressure, flow, and volume. Real-time visualization of the pressure curve is crucial for
monitoring during volume-controlled ventilation, in which pressure is the dependent variable.
Analysis of the pressure curve has little clinical utility during pressure-controlled ventilation, in
which the dependent variable is the flow waveform, which varies according to changes in the
mechanics of the respiratory system. Pressure-volume loops and flow-volume loops provide useful
information on the dynamic trends of the respiratory system compliance and resistance, respec-
tively. Modern ventilators provide complete monitoring of respiratory system mechanics, which is
our guideline for optimizing ventilatory support and avoiding complications associated with me-
chanical ventilation. Key words: respiratory mechanics, lung compliance, lung resistance, mechanical
ventilation, waveforms. [Respir Care 2005;50(1):55 65. 2005 Daedalus Enterprises]

Introduction Respiratory mechanics measurements can be assessed


in a dynamic condition (no flow interruption) or a static
The aim of this review is to identify and interpret the condition (occlusion techniques). Ventilators provide an-
data provided by modern ventilators that provide the great- alog (waveform) and digital (numeric) output to record
est clinical help for a correct evaluation of respiratory compliance and resistance and to monitor pressure, flow,
mechanics during artificial ventilation. and volume at the bedside.

Umberto Lucangelo MD and Francesca Bernabe MD are affiliated with


the Department of Perioperative Medicine, Intensive Care, and Emer- Llus Blanch MD PhD presented a version of this article at the 34th
gency, Trieste University School of Medicine, Cattinara Hospital, Tri- RESPIRATORY CARE Journal Conference, Applied Respiratory Physiology:
este, Italy. Llus Blanch MD PhD is affiliated with the Critical Care Use of Ventilator Waveforms and Mechanics in the Management of
Center, Hospital de Sabadell, Institut Universitari Fundacio Parc Taul, Critically Ill Patients, held April 1619, 2004, in Cancun, Mexico.
Corporacio Parc Taul, Universitat Autonoma de Barcelona, Sabadell,
Spain. Correspondence: Llus Blanch MD PhD, Critical Care Center, Hospital
de Sabadell, Institut Universitari Fundacio Parc Taul, Corporacio Parc
This research was partly supported by grants from Red Gira and Funda- Taul, Universitad Autonoma de Barcelona, 08208 Sabadell, Spain. E-
cio Parc Taul. mail: lblanch@cspt.es.

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RESPIRATORY MECHANICS DERIVED FROM SIGNALS IN THE VENTILATOR CIRCUIT

Equation of Motion

The pressure applied to the respiratory system of a ven-


tilated patient is the sum of the pressure generated by the
ventilator (measured at the airway opening [ie, mouth]
(PAO) and the pressure developed by the respiratory mus-
cles, as described by the equation of motion:

V
PRS PAO Pmus V R k (1)
C

in which PRS is the respiratory-system pressure, PAO is the


pressure at the airway opening, Pmus is the pressure devel-
oped by the respiratory muscles, V is volume, V is flow,
R is the airways resistance, C is the respiratory-system
compliance, and k is a constant that represents the alveolar
end-expiratory pressure.
PAO, and V can be measured by the pressure and flow
transducers in the ventilator. Volume is derived mathemat-
ically from the integration of the flow waveform.
The term V R corresponds to the pressure dissipated
across the airway and the endotracheal tube, to overcome Fig. 1. Data collected during volume-controlled ventilation with
the frictional forces generated by gas flow, which, along constant flow. The pressure curve provided by Equation 2 (rhom-
boidal dots) (see text) is compared to measured airway pressure
with V determine the resistance of the respiratory system
displayed on the ventilator.
(RRS).
The term V/C, on the other hand, corresponds to the
pressure that must be applied to overcome elastic forces, Dynamic Mechanics
and V/C depends on both the volume insufflated in excess
of resting volume and on the respiratory system compli- Dynamic mechanics can be derived during partially-
ance (CRS). The respiratory system is linear in the range of supported ventilation (pressure-support ventilation) or to-
the tidal volume (VT), with constant RRS and CRS through- tally-supported ventilation (volume-controlled ventilation
out the respiratory cycle.1 [VCV]) with intubated patients, without flow interrup-
The constant k indicates the PAO value when both flow tion.3,4
and volume are zero, and it has the practical utility of Therefore, the respective values of the RRS, CRS, and k
absorbing any error that might be made in estimating func- can be obtained by fitting Equation 2 to the sample values
tional residual capacity from an integrated flow signal.2 of PAO, V, and V with a multiple linear regression analy-
The constant k takes into account the application of pos- sis, or linear least squares fitting.5 8
itive end-expiratory pressure (PEEP) or the presence of With the use of a computer, the PAO, V, and V variables,
intrinsic PEEP (auto-PEEP), if present. which change throughout the respiratory cycle, can be
When the patients breathing activity is entirely passive digitized at high speed (100 Hz), so CRS and RRS can be
(full ventilatory support), pressure developed by the respi- calculated from 100 or more equations per breath. The
ratory muscles is negligible, and the driving pressure nec- least squares fitting method does not require a peculiar
essary to move air in and out of the thorax can be de- inspiratory flow pattern; it can be applied during the whole
scribed by the simplified equation of motion: breathing cycle or only in the inspiratory or expiratory
phase. To avoid unrealistic results due to expiratory flow
limitation in chronic obstructive pulmonary disease pa-
V
PRS PAO V R k (2) tients, Volta et al9 suggest restricting the least squares
C fitting analysis to the inspiratory phase. That approach
allows the superimposition of the fitted pressure curve
The equation of motion can be applied when single- on the PAO curve, to give a visual impression of the good-
compartment models of respiratory system (ie, pipe-bal- ness of fit between the 2 pressure waves (Fig. 1). The
loon) are used to describe the dynamic relationship be- least square fitting method is less valid if the patient is
tween pressure, flow, and volume. actively breathing, because it assumes that Pmus is zero.

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Fig. 2. Time-course of static airway pressure, flow, and volume during volume-controlled ventilation. From panel A to panel C, respiratory
system compliance decreases. The constant-flow phase is defined by the dotted lines, which show the elastic load on the pressure curve.
As peak inspiratory pressure increases, the morphology of the curve changes, turning from concave to linear to convex.

One of the most-important methodological limits of the This method, despite implying a complete muscle palsy,
single linear model is that it does not take into account the allows for real-time monitoring, with an immediate visu-
variation of RRS and CRS with lung volume, and it neglects alization of hyperinflation and lung recruitment.11 From
flow turbulence and inertial forces. Moreover, RRS can be mathematical analysis of the shape of the dynamic pres-
underestimated during low-level pressure-support ventila- sure-time waveform during constant-flow ventilation in an
tion with high respiratory effort.4 animal model, Ranieri et al12 derived the so-called stress
index, to minimize the risk of ventilator-induced lung in-
Time Course of Airway Pressure During jury.
Constant-Flow Inflation
Static Mechanics
The pressure-time curve has a characteristic feature dur-
ing constant-flow VCV. At the beginning of flow, an al- The dynamic mechanical properties of the respiratory
most-vertical pressure increase occurs (because of the fric- system pertain to the situation where flow varies over
tional forces generated by gas flow), which is necessary to time, whereas the static mechanical properties are empha-
overcome the resistance of the airways and the endotra- sized during the absence of flow.
cheal tube. The curve shape then changes to a linear in- The assessment of CRS and RRS in paralyzed patients
crease and follows a given slope to its maximum value can be made during constant-flow, volume-controlled ven-
(peak inspiratory pressure [PIP]), which occurs at end- tilation, with the end-inspiratory occlusion technique.
inspiration. That course, which is normally linear, depends Many intensive-care ventilators can provide rapid air-
on the respiratory system compliance alone. As seen in way occlusion at end-inspiration. During the pause, the
Figure 2, in isovolumetric conditions the curve loses its flow drops rapidly to zero, the volume (VT) is briefly
linearity and becomes either convex or concave, according trapped inside the lung, and static airway pressure can be
to the increase or decrease in CRS.10 measured.
Similarly, during lung overdistention the curve shape is The static airway pressure waveform (Fig. 4) has a char-
concave, and becomes first linear and then convex as the acteristic trend, with the highest peak at end-inspiration
pre-set VT decreases (Fig. 3). (peak inspiratory pressure [PIP]), followed by a rapid drop

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Fig. 3. Time-course of static airway pressure, flow, and volume during volume-controlled ventilation. From panel A to panel C, volume
decreases and the shape of the airway-pressure curve changes. Panel A shows the typical airway-pressure-curve aspect during lung
overdistention.

Table 1. Relationship of Compliance to Set Inspiratory Pause Time

Compliance Pause time (s)

Static 23
Quasistatic 11.5
Dynamic 1

after the occlusion (P1 in Fig. 4), and a slow decay until a
plateau is reached (P2 in Fig. 4).
P2 is the static pressure of the respiratory system, which
in the absence of flow equals the alveolar pressure, which
reflects the elastic retraction of the entire respiratory sys-
tem. The pressure drop from PIP to P1 represents the
pressure required to move the inspiratory flow along the
airways without alveolar interference, thus representing
the pressure dissipated by the flow-dependent resistances.
The slow post-occlusion decay from P1 to P2 (see Fig.
4) depends on the viscoelastic properties of the system and
on the pendulum-like movement of the air (pendelluft).
During the post-inspiratory occlusion period there is a dy-
namic elastic rearrangement of lung volume, which allows
the different pressures in alveoli at different time constants
Fig. 4. Flow, volume, and airway pressure (Paw) during end-inspira- to equalize, and depends on the inhomogeneity of the lung
tory occlusion. Pmax maximum (peak) airway pressure. P1 points
parenchyma. The lung regions that have a low time con-
to end of the rapid post-occlusion pressure-drop. P2 points to the
end of the slow pressure-decay plateau. Cstat static compliance stant (ie, rapid zones), where the alveolar pressure rises
of the respiratory system. VT tidal volume. Cdyn dynamic rapidly, are emptied in the lung regions that have higher
compliance of the respiratory system. time constants (ie, slow zones), where the pressure rises

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Fig. 5. Progressive increase in the inspiratory pause during volume-controlled ventilation, with a consequent decrease in expiratory time,
which causes intrinsic positive end-expiratory pressure, which is evidenced by the fact that the expiratory flow wave fails to reach zero
(arrow).

Fig. 6. Volume-controlled ventilation with progressive increase in the inspiratory time, but with a constant pause. During the 2 first cycles
the flow-decrease decreases the PIP-P1 (see text) pressure gradient, while P2 (see text) remains unchanged, because the expiratory time
is enough to avoid hyperinflation. Starting at the third cycle there is a progressive increase in P2, which tends to the peak inspiratory
pressure value. During the last cycle the pause is no longer recognizable, because of the extreme decrease in expiratory time, which leads
to air trapping, increase in PIP, and risk of barotrauma.

more slowly because of higher resistance or lower com- Cdyn VT/PIP (4)
pliance (see Fig. 4).1318
The concepts that we just expressed are indispensable to The static compliance of the respiratory system mirrors
understanding the difference between the static compli- the elastic features of the respiratory system, whereas the
ance (Cstat) and the dynamic compliance (Cdyn) of the dynamic compliance also includes the resistive (flow-de-
respiratory system. For static compliance the volume vari- pendent) component of the airways and the endotracheal
ation refers to the static plateau pressure (P2). For dy- tube. The pressure gradient P1-P2 is based on the intrapul-
namic compliance the volume variation refers to PIP. Thus: monary post-occlusion dynamic phenomena that we de-
scribed above.
Cstat VT/P2 (3) When the inspiratory pause is shorter than 2 seconds, P2
does not always reflect the alveolar pressure. The compli-
and ance value thus measured is called quasi-static compliance

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(see Fig. 4). In healthy subjects the difference between


static compliance and quasi-static compliance is minimal,
whereas it is markedly higher in patients who have acute
respiratory distress syndrome or chronic obstructive pul-
monary disease.
Table 1 shows how the respiratory system compliance
varies in relation to the length of the inspiratory pause set
on the ventilator.19 Compliance based on the length of the
set inspiratory pause varies from a static to a dynamic
condition, and takes on different values and clinical im-
portance.
If the operator wishes to include an inspiratory pause in
the ventilatory setting, attention must be paid to the pos-
sible effects on the expiratory phase. Complete lung emp-
tying may be prevented by decreasing expiratory time (Fig.
5). Fig. 7. Pressure curve measured at the mouth (static airway pres-
At the end of a normal expiration in a normal subject, sure [Paw]) and at the end of the endotracheal tube (Ptr). The similar
trend of the 2 curves only differs in the amount of pressure dissi-
the alveolar pressure is nearly zero. Expiratory flow lim- pated to overcome the resistance of the endotracheal tube (Pet).
itation, or an inadequate respiratory pattern (high VT or During the end-inspiratory pause, the pressure gradient at the
high respiratory rate) cause auto-PEEP, due to volume extremities of the endotracheal tube is zeroed, and both curves
trapping. Auto-PEEP is detectable during the post-expira- settle on the same P2 value (see text).
tory occlusion maneuver.
Therefore, compliance must be calculated with the fol- PIP represents the sum of the pressures applied by the
lowing formula, which also takes into consideration the ventilator to overcome the elastic and resistive forces of
possible use of PEEP:20 the respiratory system (airways and endotracheal tube). In
isovolumetric conditions, variations in PIP depend on the
VT pressure dissipated to overcome that resistance, so airway
CRS (5) secretions, bronchospasm, and the diameter of the endo-
Paw (PEEP PEEPi) tracheal tube affect PIP. The resistance exerted by the
endotracheal tube can be calculated by a modern ventilator
The rapid-occlusion technique during constant-flow in- or measured with a dedicated catheter. In this case, PIP
flation allows measurement of respiratory system resis- measured at the trachea is lower than the corresponding
tance when the respective pressure gradients (PIP-P2), (PIP- value measured at the mouth, because of the amount of
P1), and (P1-P2) are divided by the flow value (V) pressure dissipated by the endotracheal tube, as shown in
immediately before occlusion. The ratio of (PIP-P1) to V Figure 7. That amount of pressure should not be consid-
is the airway flow-dependent resistance, which is com- ered in the assessment of the risk of barotrauma, because
monly called initial or minimal or ohmic resistance it does not have any consequence at the alveolar level.
(initial RRS). When the (P1-P2) pressure gradient is taken It must be emphasized that P2 (an indicator of compli-
into account, the additional lung resistance (ie, the change ance) may also be measured with a nonconstant-flow wave,
in RRS) is obtained, which reflects the pendelluft phenom- as shown in Figure 8.21 Furthermore, the end-inspiratory-
enon and the visco-plasto-elastic lung and thorax behavior. occlusion maneuver can identify a leak in the respiratory
The total resistance, which takes into consideration the circuit, because if there is a leak, the plateau pressure can-
PIP-P2 pressure gradient, represents the sum of initial RRS not be reached. In short, real-time visualization of the
plus the change in RRS. pressure curve is crucial for monitoring during VCV, be-
In clinical practice, it is important to remember that the cause pressure is a dependent variable in the system. Vol-
PIP-P1 pressure gradient is flow-dependent, whereas P2 is ume-controlled ventilation also includes the use of de-
affected only by variations in volume and/or compliance. scending-ramp and sinusoid flow waves, which correspond
Figure 6 shows that during constant-flow VCV the inspira- to the respective pressure waves seen in Figure 9.
tory time is gradually increased, which decreases the height On the other hand, the analysis of the pressure curve has
of the flow wave. There is a progressive decrease in the limited clinical utility during pressure-controlled ventila-
PIP-P1 gradient and in initial RRS, and a contemporaneous tion (PCV). In that case the dependent variable is flow,
increase in the plateau pressure, which reflects the estab- which changes as the features of the respiratory system
lishment of a ventilatory pattern with inverted ratios, which change: the ventilator will constantly adjust flow so that
generates auto-PEEP. the inspiratory pressure is maintained during the entire set

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Fig. 8. Pressure controlled ventilation (PCV) with the characteristic flow-descent. The presence of an adequate pause at end-inspiration
allows identification of the plateau pressure. The prolongation of inspiratory time in the third cycle produces an additional amount of volume.

Fig. 9. Volume-controlled ventilation waveforms, with a constant, descending ramp and sinusoid flow. In the 2 last situations, measuring
resistance becomes useless, whereas estimating the P2 value (see text) remains clinically valid.

inspiratory time. During PCV the flow wave in Figure 8 corresponds to the alveolar pressure, which is only linked
has the characteristic descending shape that reaches zero at to the elastic component of the system, as the elastic com-
the third breath, with a prolongation of the inspiratory ponent is zero, because of the absence of flow. Further-
time. In that case the working pressure set on the ventilator more, an additional amount of volume is obtained, as com-

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Fig. 10. Different flow shapes at different mechanical loads during pressure-controlled ventilation. A: Resistance variations. B: Compliance
variations.

Fig. 11. The first cycle is characterized by slow attainment of the set working pressure (low slope) that stops at 16 cm H2O, causing
hypoventilation. Set working pressure (25 cm H2O) is reached by increasing pressurization in the following breath. Dampening waves are
recognizable in the last cycle.

pared to the 2 first breaths, where the inspiratory flow is ratory system compliance and the resistance. In Figure
truncated. The respective volume waveforms show the vol- 10A, the flow wave varies as resistance increases and the
ume increases. Further prolonging the inspiratory pause compliance remains constant. As the resistive load in-
decreases the expiratory time, which leads to gas-trap- creases, the flow loses its characteristic descending aspect
ping.22 and becomes almost constant. On the other hand, when
In the inspiratory flow waveform, 2 phases can be ob- compliance decreases as the resistive load remains stable,
served: the initial peak, which corresponds to the system the morphologic features of the flow wave are not altered,
pressurization, and a second segment that descends with a but the wave is interrupted early, which leads to a decrease
variable slope. The latter is a function of both the respi- in the tidal volume (see Fig. 10 panel B).

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Fig. 12. Pressure-volume loops from volume-controlled ventilation. A: Pressure increase related to the volume increase, with identification
of the upper inflection point. B: Pressure increase related to the decrease in compliance. On the inspiratory limb, the lower inflection point
(arrow) occurs at higher pressure as the compliance decreases.

Fig. 13. Pressure-volume loops from pressure-controlled ventilation. A: Changes in loop caused by changes in compliance. B: Changes in
loop caused by changes in resistance.

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Fig. 14. The effect of resistance is only evidenced on the expira-


tory limb of the flow-volume loop, with a decrease in the expiratory
flow peak, without affecting the inspiratory flow pattern.

Pressure-controlled ventilation strategies, such as PCV


and pressure-support ventilation, depend on the rapid
achievement of the working pressure set on the supplying
system. Modern ventilators allow a variation in the slope
of the pressure curve. Figure 11 shows that during PCV at
25 cm H2O a slow attainment of the set working pressure
does not guarantee an adequate volume. Increasing the rate Fig. 15. Air leak is evidenced by the failed closure of the flow-
volume loop (bottom panel) and by failure to reach zero on the
of pressurization creates the characteristic square wave expired volume curve.
pressure curve. An exaggerated pressurization may be ev-
idenced by the presence of dampening waves during the
remaining inspiratory time.23 is a consequence of the change in the respiratory system
compliance, in isovolumetric conditions, as evidenced by
Pressure-Volume and Flow-Volume Loops the rightward shift of the loop.
During PCV the P-V loop provides a real-time visual-
ization that the VT depends on compliance and on resis-
Pressure-volume (P-V) and flow-volume (F-V) loops tance. In this case the supplied volume changes, while the
provide information on the dynamic trend of, respectively, working pressure remains constant (Fig. 13).
the respiratory system compliance and resistance. In par- F-V loops are particularly important for assessing the
ticular, the P-V loop is useful for detecting lung overdis- response to bronchodilator administration during VCV (Fig.
tention during constant-flow VCV. As shown in Figure 14). F-V loops enable clinical analysis of the therapeutic
12A, increasing VT to 800 mL produces a sharp change effect.24 26 The F-V loop is also useful for identifying air
in the slope of the inspiratory P-V curve. That bend in the leaks that would not be identified with dynamic monitor-
curve is known as the upper inflection point, above which ing of the flow and pressure curves. In Figure 15 the F-V
small volume increases produce large pressure increases. loop is incomplete because of early truncation of the ex-
The difference in location of the 3 loops in Figure 12B piratory phase, caused by a loss in volume.

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When the loops are used to monitor respiratory func- ume-pressure curve of the respiratory system predicts effects of PEEP
tion, it is clinically useful to freeze a baseline curve to use in ARDS: occlusion versus constant flow technique. Am J Re-
spir Crit Care Med 1994;149(1):1927.
as a reference for following modifications.
12. Ranieri VM, Zhang H, Mascia L, Aubin M, Lin CY, Mullen JB, et
al. Pressure-time curve predicts minimally injurious ventilatory strat-
Summary egy in an isolated rat lung model. Anesthesiology 2000;93(5):1320
1328.
Thanks to new technologies, modern ventilators allow 13. Gottfried SB, Rossi A, Higgs BD, Calverley PM, Zocchi L, Bozic C,
Milic-Emili J. Noninvasive determination of respiratory system me-
complete monitoring of respiratory mechanics, which must
chanics during mechanical ventilation for acute respiratory failure.
become a guideline for optimizing and personalizing ven- Am Rev Respir Dis 1985;131(3):414420.
tilatory support, in order to avoid the risk of barotrauma 14. Rossi A, Gottfried SB, Higgs BD, Zocchi L, Grassino A, Milich-
and volutrauma. Emili J. Respiratory mechanics in mechanically ventilated patients
with respiratory failure. J Appl Physiol 1985;58(6):18491858.
15. Rossi A, Gottfried SB, Zocchi L, Higgs BD, Lennox S, Calverley
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Discussion for instance, the static compliance is pneumothorax, and you are ventilat-
low and you happen to be ventilating ing a very low lung volume, and the
Harris: I have a difficult time with a patient, perhaps with a high lung compliance is also low. Those are 2
the concept of static compliance with- volume, and theyre on the descend- very different situations, and yet that
out knowing absolute lung volume. ing limb of the P-V curve. Or take the number may look very similar, so I
You can imagine a situation where, opposite situation, where you have a have a difficult time interpreting it.

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Do you think static compliance is a The ARDS Network trial1 was very waveform during inspiration is asso-
useful number without knowing what eye-opening for me, because the small- ciated with minimal lung injury, and
the lung volume is? tidal-volume group had the best mor- this phenomenon was independent of
tality, but they also had the worst gas the total lung volume. Perhaps this is
Blanch: Static compliance reflects exchange and the worst compliance. I what happened in the patients in the
the behavior of the total respiratory think thats a very important lesson treatment arm in the ARDS Network
system. Assessment of regional lung for all of usthat these mechanical study. A tidal volume of 6 mL/kg com-
volume is not possible at the bedside. and gas exchange targets weve grown bined with a moderate PEEP did not
In ARDS [acute respiratory distress up with and spend a lot of time study- allow both complete lung recruitment
syndrome] different lung regions have ing are only part of the story. Your at end-expiration and tidal recruitment
different mechanical properties and presentation was excellent in review- and derecruitment, thus avoiding fur-
different time constants, and some re- ing the physiologic principles, but I ther damage inflicted by positive-
gions might be collapsed or consoli- think weve got to be really careful in pressure ventilation.
dated. Therefore, it is rather difficult looking at these global measurements
to set the ventilator according to the of lung function and making the leap Hess: Neil [MacIntyre] brought up
compliance. I think there are other sim- that they should be the guide to me- a very important point, because there
ple variables that we need to look at; chanical ventilation strategies. are, I think, 2 schools of thought about
one of the most important is airway managing ARDS. One is, If I keep
plateau pressure. With a patient who the plateau pressure less than 30 cm
REFERENCE H2O, then everything is OK. The
has ARDS, plateau pressure higher
than 30 32 cm H2O invariably causes 1. Ventilation with lower tidal volumes as other is, I should try to lower the
overdistension in some lung regions. compared with traditional tidal volumes for tidal volume to 6 mL/kg and have a
acute lung injury and the acute respiratory plateau pressure as low as possible. I
Interestingly, some investigators have
distress syndrome. The Acute Respiratory
found overdistended areas at end-ex- Distress Syndrome Network. N Engl J Med
think, Neil, thats what you were get-
piration with PEEP of 12 cm H2O, 2000;342(18):13011308. ting at, and I think Neils point was
perhaps reflecting overpressurized that maybe there are some problems if
trapped gas. A relatively normal com- Blanch: I agree. My presentation we just say, Lets just keep the pla-
pliance measurement would reflect the was focused to explain the physiologic teau pressure less than 30 cm H2O
ability to accept more tidal volume at principles behind those measurements, regardless of the tidal volume and ev-
reasonable plateau pressure. Whether although to set the ventilator accord- erything will be OK.
or not some patients with moderate ingly remains difficult. I agree with
lung injury would benefit from this you that ventilation with low PEEP MacIntyre: That was part of what I
breathing pattern is a matter of de- and low tidal volume favors lung col- was getting at. However, I would like
bate. lapse, so compliance measurements to challenge an even more fundamen-
are affected in the same direction, be- tal concept, and that is this concept
MacIntyre: This question is prob- cause less lung is available for venti- that if the radiograph or CT [computed
ably going to come up multiple times lation. At the bedside we need a tool tomogram] shows that weve recruited
in this conference, but Ill introduce it to assess whether there is alveolar the lung units that were collapsed, then
here on the first day. Are global mea- over-stretching or repetitive closing- weve done a good thing. Im chal-
surements of compliance or any and-opening during each tidal breath. lenging that assumption because it ig-
other mechanical propertiesreally Looking at static P-V curves, it is easy nores the effect on the already-open
what we ought to be aiming for? In to identify a pressure point beyond units. Maybejust maybewe may
ARDS the lung is heterogeneously in- which overdistention occurs. How- have to sacrifice a few alveoli, if
jured: some regions are very sick, ever, in setting a PEEP level higher you will; let them stay collapsed be-
while other regions, although not very than the lower inflection point, clini- cause it protects the healthier regions
healthy, are at least less sick. Im afraid cians cannot rule out the possibility of of the lung from overdistention. Per-
that a lot of times our measurements repetitive alveolar opening-and-clos- haps the concept and accepted stan-
are only looking at what were doing ing. dard of a wide-open, beautiful, black
with the sick region. If we pop them Recent experimental research sug- CT chest scan may in fact be masking
open, overall compliance looks a lot gests that the shape of the pressure- regional overdistention of healthier
better. But were not so good at look- time curve during volume-controlled units and producing a worse outcome.
ing at what were doing to the health- ventilation at constant square flow is
ier regions of the lung when we try to a useful tool to optimize mechanical Dhand: I think the question that was
open the sick regions. ventilation. A straight pressure-time raised by Scott [Harris] is really the

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RESPIRATORY MECHANICS DERIVED FROM SIGNALS IN THE VENTILATOR CIRCUIT

central issue, because we dont know lapse unless very high PEEP levels are recruitment strategy and the conven-
the lung volume at which we are ven- applied at end-expiration. tional, low-PEEP strategywhich
tilating a patient. If we knew that, then will most certainly subject some closed
we would know where in the P-V curve REFERENCE units to high stress as they openlies
we were and what the limitations are. 1. Villagra A, Ochagavia A, Vatua S, Murias an optimum strategy. The problem is
Why is it so difficult for us to measure G, Del Mar Fernandez M, Lopez-Aguilar J, that we dont know exactly where we
or even estimate what the lung vol- et al. Recruitment maneuvers during lung- are on the P-V curve. Thats the big
ume is at which the patient is being protective ventilation in acute respiratory
distress syndrome. Am J Respir Crit Care
issue. Theres no tool at the bedside
ventilated? The plateau pressure is just Med 2002;165(2):165170. you can pull out of your pocket that
a surrogate measurement. When we will say, This is where I should be to
are giving a small tidal volume to a Sanborn: I wanted to come back to satisfy that compromise.
patient who is on the flat portion be- Neils issue. Its an issue of compro-
low the lower inflection point, then mise, it seems to me. If you believe
that might be harmful. Likewise, if MacIntyre: I agree with you com-
the lung should be completely recruit- pletely. The point I was trying to make
the patient is at the very top of the edforgetting for the moment that we
P-V curve, then it could be harmful, is exactly thatthat we dont know
recognize primary and secondary
so what we really need to know is where we are, and that this oversim-
ARDSyou could inflate the lung to
where on that curve we are when ven- plification of the CT scan or the steep
maximum inspiratory capacity and
tilating the patient. part of the deflation limb of the curve
make the CT scan all black, and we
know that lung units would be over- as the ideal place to place the lung is,
Blanch: I agree with you. We per- distended. So by ventilating in the up- I think, just thatan oversimplifica-
formed recruitment maneuvers in pa- per region of the P-V curve with high tion.
tients with ARDS and found that at high PEEP we are probably accepting some
PEEP, recruitment maneuvers had little overdistention. If you choose to ven- Hess: I am reminded of something I
or no effect.1 Interestingly, when the tilate the lower, gravity-down region heard someone say a couple of years
lung-volume increase induced by PEEP with low PEEP, then we are accepting ago. We know that if we overdistend
was high, a recruitment maneuver had that, with each inflation-deflation cy- the lung, thats bad. We know if we
little effect on oxygenation. Alveolar cle, the consolidated lung units will allow alveoli to open and close, thats
units not stabilized with high PEEP undergo excessive and destructive bad. But if its closed and we just leave
might be recruited at high airway pres- shear stress. So it seems to me that it alone, maybe thats OK. We just
sure, although they are prompt to col- somewhere in between the maximum- dont know.

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