British Journal of Anaesthesia 97 (1): 57–63 (2006)

doi:10.1093/bja/ael115 Advance Access publication May 19, 2006

New ventilators for the ICU—usefulness of lung

performance reporting
P. D. Macnaughton*

Critical Care Unit, Derriford Hospital, Plymouth PL6 8DH, UK

*E-mail: peter.macnaughton@phnt.swest.nhs.uk
Monitoring the functional and mechanical properties of the lungs during positive pressure
ventilation may assist in confirming the underlying pulmonary diagnosis, allow therapeutic
interventions to be accurately assessed and provide information that ensures the optimal
setting of the ventilator parameters and encourages timely weaning. This article reviews the
range of lung function measurements, both continuous and intermittent, that may be undertaken
during mechanical ventilation. The monitoring capability of ICU ventilators is increasing in
complexity.

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Br J Anaesth 2006; 97: 57–63
Keywords: equipment, ventilators; monitoring, intensive care; ventilation

Although the correction of abnormal arterial blood oxygen
and carbon dioxide (CO2) tensions is the main goal of
mechanical ventilation, it is of note that an intervention
which improves gas exchange does not necessarily improve
patient outcome. Nitric oxide inhalation has been shown
to improve oxygenation but not outcome.11 Similarly,
prone ventilation is associated with a significant improve-
ment in gas exchange but in a large multicentre randomized,
controlled trial there was no effect upon patient mortality.9
Interventions that improve gas exchange have even been
associated with an adverse effect upon outcome. In the
ARDSnet trial which compared high and low tidal volumes
in acute lung injury, gas exchange as reflected by the
PaO2 :F IO2 ratio was significantly higher in the high tidal
volume group up to day 7 of the trial.3 However, despite
causing improved gas exchange, high tidal volume ventila-
tion was associated with an increased absolute mortality of
8.8% compared with using low tidal volumes. This land-
mark study confirmed that how the ventilator is set has a
significant influence upon mortality and that an improve-
ment in blood gas tensions does not imply that the patient is
receiving optimal ventilatory support.
The ARDSnet tidal volume trial confirmed the large body
of evidence from laboratory studies that positive pressure
ventilation can itself cause and exacerbate lung injury.38 The
application of excessive tidal volumes that result in
hyperinflation (‘volutrauma’) appears to be the most impor-
tant cause of ventilator-induced lung injury (VILI). Cyclical
opening and closing of atelectatic lung regions during tidal
breathing (‘atelectrauma’) appears to be the other major
contributory factor. Lung protective ventilation has been
described as ensuring maximal recruitment of collapsed
areas of the lung, avoiding regional hyperinflation and
preventing cyclical recruitment–derecruitment during tidal
ventilation.2 The increasing range of measurements
available during mechanical ventilation should assist the
clinician in the optimal setting of the ventilator.
Static measurements
Compliance and resistance
The basic mechanical properties of compliance and
resistance are readily measured during volume control ven-
tilation with constant flow inspiration (Fig. 1).10 There must
be an adequate end inspiratory pause in order that the
inspiratory plateau pressure can be accurately measured
and there should be no leak in the respiratory circuit. If
intrinsic PEEP is present, the compliance value will be
underestimated if the end-expiratory pressure measured in
the airway is used. Total PEEP should be measured after
an end-expiratory pause (see below) as this reflects the true
end-expiratory pressure within the lungs.
A static compliance (Crs.st) less than 50 ml per cm H2O is
commonly encountered in ICU and patients with severe
acute respiratory distress syndrome (ARDS) may have
values less than 20 ml per cm H2O.10 Monitoring compli-
ance may be useful for assessing the effectiveness of lung
recruitment or the occurrence of lung over-distension after
adjustments to ventilator settings. The change in compliance
that occurs after the application of PEEP may differentiate
between lung recruitment or hyperinflation.32
When interpreting the measured values of Crs.st, the
influence of the chest wall compliance (CW) should be
considered. Chest wall abnormalities, increased muscle
tone and abdominal distension may all reduce chest wall
compliance. In order to measure the two components of
compliance (CL and CW), an oesophageal balloon is used

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 Macnaughton
60
. Table 1 Airway resistance (cm H2O litre
1 s) in a range of different clinical
Flow, V
–1
litre s
I time
0
40
Pressure, Ppeak P2
Pexp
cm H2O
P1
0
Fig 1 Pressure and flow curves during constant flow ventilation: tidal
volume (Vt)=V_ ·I time (constant flow inflation); total respiratory system
static compliance (Crs,st)=Vt/(P2
Pexp); total respiratory system
dynamic compliance (Crs,dyn)=Vt/(P1
Pexp); airway resistance min
(Raw)=(Ppeak
P1)/V_ ; airway resistance max (Raw)=(Ppeak
P2)/V_ .
to estimate pleural pressure. Some ventilators provide an
auxillary pressure port that can be used for this measure-
ment, which allows a complete evaluation of the elastic
properties of the respiratory system.30
Airway resistance is calculated from the airway pressure
change after an airway occlusion during a constant inspira-
tory flow (Fig. 1). In constant flow ventilation, the airway
pressure changes that occur at the end of inspiration can be
used. Minimum inspiratory airway resistance is calculated
from the immediate decrease in airway pressure (P1).
Maximum resistance, which includes the additional resis-
tance attributable to stress relaxation and time constant
inequalities, can be calculated using the inspiratory plateau
pressure (P2). If measurements of resistance are undertaken
with the inspiratory flow set at 60 litre min
1 (1 litre s
1),
the total airway resistance in cm H2O litre
1 s can be
obtained simply from the difference between the peak
and plateau airway pressures (1 cm difference=resistance
of 1 cm H2O litre
1 s). Typical values of resistance mea-
sured in ventilated patients are presented in Table 1. The
increase in airway resistance observed in ARDS and cardio-
genic pulmonary oedema may reflect oedema in the airway
wall and the presence of fluid or secretions within the
airway lumen.10 An additional factor is a reduction in the
number of patent airways because of the marked loss of
functional lung volume. Monitoring airway resistance
together with compliance is of use when interpreting the
cause of an increased airway pressure during mechanical
ventilation and to quantify the response to a bronchodilator.
Static pressure–volume curve
The static pressure–volume (PV) curve provides a more
complete evaluation of the elastic properties of the respira-
tory system. Previously this was undertaken by recording
the change in static airway pressure that occurred after a
series of progressive 100 ml increases in lung volume
58
conditions [mean (SD)]. *From Ref. 43
Normal spontaneous breathing 2.5
Normal ventilated 4.2 (1.6)
Cardiogenic pulmonary oedema* 12.1 (5.5)
ARDS* 15.5 (4.6)
Chronic airflow limitation* 26.4 (13.4)
1000
Upper inflection point, UIP
800
Volume (ml)
600
400
Lower inflection point, LIP
200
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0
0 10 20 30 40 50
Pressure (cm H2O)
Fig 2 Static PV curve. LIP defines optimal PEEP level while UIP
defines maximal lung inflation pressure (end inspiratory pressure).
introduced with a large calibrated syringe (supersyringe)
during a prolonged apnoea. Alternatively the multiple occlu-
sion technique could be used where the individual inspira-
tory plateau pressures obtained after a series of random
changes in tidal volume set on the ventilator between func-
tional residual capacity (FRC) and total lung capacity (TLC)
were recorded.18 A number of ventilators now offer the
ability to construct a static PV curve using the slow inflation
technique.34 A preset volume is applied slowly, usually over
a period of 15–20 s. The low flow rate minimizes the airway
pressure changes that arise from resistive forces. Accurate
measurements require that the patient is deeply sedated and
that a neuromuscular blocking agent has been administered
in order that there are no spontaneous respiratory efforts
during the manoeuvre.
From the PV curve a lower inflection point (LIP) and
upper inflection point (UIP) may be determined (Fig. 2).
Traditionally the LIP is thought to reflect the opening of
atelectatic areas of the lung and the pressure that PEEP
should be set above in order to ensure that lung recruitment
is maintained throughout tidal breathing. The UIP is con-
sidered to reflect the decrease in lung compliance from
hyperinflation and the upper airway pressure that should
not be exceeded in order to minimize the risk of VILI.18
There remains considerable debate as to the interpreta-
tion and utility of static PV curves.14 20 Computed tomogra-
phy (CT) scan studies have revealed that recruitment occurs
throughout the inspiratory phase of the PV curve above the
LIP.1 7 The presence or absence of a LIP does not predict
 Ventilators for lung performance reporting
whether the application of PEEP will be effective in pro-
ducing recruitment.23 Furthermore, the process of under-
taking a static PV curve may induce changes that are not
a true reflection of what happens to the lungs during tidal
breathing. Reducing the PEEP level to zero and allowing a
prolonged expiration may cause significant de-recruitment
that would not be present during ventilation with a normal
ventilatory frequency.35 The PV curve may also be influ-
enced by changes in chest wall compliance caused by
abdominal distension in extra pulmonary ARDS.24 It
appears that ventilation during tidal breathing follows the
deflation limb of the PV curve and a point of maximum
curvature has been described which equates to the onset of
de-recruitment which may be a more appropriate pressure
to guide the setting of PEEP.12 The ability to undertake the
measurement of PV curves in proprietary ICU ventilators
will allow the role of this measurement in clinical practice
to be established.
Dynamic measurements
Ventilation is a dynamic process and although easy to under-
take, static measurements may not be the most appropriate
method to assess lung mechanics and performance in the
clinical setting. Furthermore, static measurements usually
require that the patient is sedated and ventilated and that
continuous flow ventilation (volume control) is used. Many
ICU ventilators continuously display pressure, volume and
flow measurements and plot dynamic PV loops. Inter-
pretation is difficult as it is impossible to differentiate the
resistive and elastic components of the waveform.35 A
dynamic PV loop recorded during pressure control
ventilation or volume control with decelerating inspiratory
flow does not give any information regarding changes in
lung compliance during inspiration and no inference can be
made regarding the onset of recruitment or hyperinflation.
However, during constant flow ventilation (i.e. volume
control) a curving of the PV plot towards the end of
inspiration suggests decreasing compliance and possible
over-distension.35
Dynamic measurement of compliance and resistance
The airway pressure (P) at any time point (t) during positive
pressure ventilation can be predicted by the equation of
motion for the relaxed respiratory system:
PðtÞ¼½V_ ðtÞ·Rrsþ½VolðtÞ/Crs+PEEPtot:
As the ventilator continuously measures airway pressure
(P), flow (V_ ) and volume (Vol), in theory if three simulta-
neous sets of data are collected, the three unknown values of
compliance, resistance and total PEEP can be calculated. A
more accurate estimate of the actual values will be obtained
if a large number of sets of data are processed. With
a sampling rate of 60 Hz some 180 data points will be
analysed over the whole respiratory cycle with a ventilatory
59
frequency of 20 bpm. Using the least squares method the
values of best fit are computed for airway resistance, respira-
tory system compliance and total PEEP.28 The advantage
of this method is that the lung mechanical parameters can be
measured during any ventilator mode with any inspiratory
flow pattern provided that the patient is relaxed.13 There is
no requirement for an end inspiratory or expiratory pause
although it will be inaccurate if the patient is making
spontaneous respiratory efforts.33 Intrinsic PEEP can be
estimated from the difference between the calculated total
PEEP and the applied PEEP. However, this measurement
does not appear particularly accurate in patients with
significant airflow limitation42 when static measurements
of intrinsic PEEP are most useful clinically. If data
collected from the whole respiratory cycle are used in the
calculation, the assumption is that resistance and compli-
ance remain constant. This may be a significant source of
error as resistance tends to decrease with increasing lung
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volume, while compliance may vary during inspiration
according to which part of the PV curve the lung is operating
on (see below).
Stress index
Changes in compliance during inspiration can be inferred
from the analysis of the slope of the airway pressure–time
plot in constant flow inspiration. A linear slope implies that
compliance remains constant and that recruitment or over-
distension are unlikely to be occurring during tidal ventila-
tion. If the slope increases towards the end of inspiration,
this suggests that the compliance has reduced at the end of
inspiration and that hyperinflation is occurring. If the slope
reduces during inspiration compliance is increasing sug-
gesting that lung recruitment is occurring. The change in
the slope of the airway pressure–time curve can be
expressed mathematically which has been termed a ‘stress
index’ and a possible method for monitoring the optimal
setting of ventilatory support.31 This analysis is limited to
constant flow inspiration and to date has only been applied
to animal models.
Volume-dependent compliance measurements
The equation of motion assumes that resistance and com-
pliance are constant over the period that data are collected.
This may not be valid and an analysis of the change in
compliance during inspiration has been proposed where
the breath is divided into six segments and the equation
of motion solved for each segment.25 This allows the change
in compliance during inspiration to be plotted. Compliance
that increases during inspiration suggests recruitment while
a compliance that decreases with increasing volume
suggests over-inflation. This type of analysis may allow
dynamic assessment of recruitment or hyperinflation during
tidal breathing.
 Macnaughton

Tracheal PV loops and dynostatic algorithm
Some ventilators offer the facility to measure tracheal pres-
sure directly through a tracheal catheter introduced through
the tracheal tube. Measuring tracheal pressure removes the
influence of the resistance of the tracheal tube and signifi-
cantly changes the appearance of the dynamic PV loop.34 A
more accurate estimate of end inspiratory and expiratory
pressures is obtained and assuming that the airway resis-
tance is low, tracheal pressure will be a reasonable reflection
of alveolar pressure. This results in a valid estimate of
compliance measured under dynamic conditions.
The difference between tracheal and alveolar pressure
which arises from airway resistance can be estimated
from analysis of tracheal pressure and flow data collected
at matching lung volumes during inspiration and expira-
tion.16 If inspiratory and expiratory resistance are assumed
to be identical at the same lung volumes, alveolar pressure
can be predicted from the equation of motion and has been
during dynamic ventilation. With this analysis, an estimated
‘static’ alveolar PV plot can be produced during any mode
of ventilation and without the need for an end inspiratory
pause (Fig. 3). The dynostatic algorithm PV curve typically
shows much greater changes in volume-dependent com-
pliance than if compliance is calculated conventionally
and can be used to indicate over-distension during tidal
ventilation.
Intrinsic PEEP and gas trapping
Minimizing intrinsic (PEEPi) and the associated hyperinfla-
tion are central to the ventilatory strategy for patients with
severe airflow limitation attributable to COPD or asthma.27
The adverse effects of PEEPi include increased inspiratory
work of breathing during spontaneous ventilation, reduced
ability to trigger the ventilator during assisted modes of

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termed the dynostatic pressure (Pdynostatic): ventilation, adverse haemodynamic effects of increased intra-
If thoracic pressure and an increased risk of barotrauma.5 The
presence of PEEPi can be inferred by inspection of the flow
Vol time waveform which will reveal that expiratory flow has
Palv ¼ þ PEEPtot;
Comp not reached zero before the next inspiration. Static PEEPi is
measured by applying an end-expiratory pause, which holds
then
the ventilator in expiration with the expiratory valve
ƒ ðPinsp
Palv Þ closed.21 If PEEPi is present the recorded airway pressure
Pinsp ¼Palv +V insp ·Rinsp !Rinsp ¼ ƒ ;
V insp will increase during the expiratory pause to reflect the true
end-expiratory alveolar pressure. Some ventilators automate
ƒ ðPexp
Palv Þ the procedure and immediately after the measurement of
Pexp ¼ Palv þ V exp ·Rexp !Rexp ¼ ƒ ;
V exp PEEPi, are able to quantify the hyperinflation by allowing
the expiratory valve to open and measuring the volume
ƒ ƒ
ðPexp ·V insp
Pinsp ·V exp Þ exhaled to zero positive end expiratory pressure. Static mea-
Pdynostatic ¼ Palv ¼ ƒ ƒ : surements of PEEPi require that the patient is relaxed and
ðV insp
V exp Þ
not making any inspiratory efforts which usually means that
The calculation is repeated at a number of different heavy sedation and a neuromuscular blocking agent need to
volumes and alveolar pressure is plotted against volume be administered. A dynamic measurement of PEEPi can be

600

500 Dynostatic P/V curve

Tracheal P/V loop
part
olated
Extrap
400
Volume (ml)

insp exp UIP

Isovolume
300 plane
rt
pa

exp insp
d
te

200 LIP
la
cu
al
C

100 t
d par
polate
Extra
0
0 5 Pexp 10 15 20 Pinsp 25 30
Pressure (cm H2O)

ƒ ƒ ƒ ƒ
Fig 3 Dynostatic alveolar PV curve. Alveolar pressure is calculated according to the equation: Pdynostatic=(Pexp·V insp
Pinsp·V exp)/(V insp
V exp).
Every point on the dynostatic curve (Pxdyn) is calculated using pressure and flow values at isovolume levels (indicated by broken lines) during
inspiration and expiration in the tracheal P/V loop. Reproduced from Karason and colleagues, with permission from Blackwell Publishing.44

60
 Ventilators for lung performance reporting
obtained by recording the pressure change that occurs before
inspiratory flow commences during inspiration. If the
patient is not making any spontaneous efforts this can be
measured from the change in airway pressure. However,
when the patient is spontaneously breathing, oesophageal
pressure needs to be recorded (as an estimate of pleural
pressure) and dynamic PEEPi is extrapolated from the
change in oesophageal pressure which occurs before inspira-
tory flow commences. Dynamic measurements reflect the
lowest regional value of PEEPi and may be considerably
less than static measurements in patients with airflow lim-
itation who typically have significant inhomogeneity.22
Measurements of PEEPi should be made without any
external PEEP applied. The value of static PEEPi observed
in patients with chronic airflow limitation undergoing
mechanical ventilation depends upon the airway resistance
and on the applied ventilatory parameters (tidal volume,
expiratory time and ventilatory frequency). Values up to
20 cm H2O are not uncommon and measurements of
PEEPi may be used to assess the response to bronchodilators
and to titrate ventilatory settings, with a reasonable aim to
maintain PEEPi less than 10 cm H2O. The increased inspira-
tory work of breathing caused by PEEPi is reduced by the
application of external PEEP, which may be of benefit dur-
ing spontaneous ventilatory modes.5 There is little evidence
that matching PEEPi with externally applied PEEP has any
significant benefit in patients who are fully ventilated and
not making spontaneous respiratory efforts.
Volumetric capnography
This describes the continuous measurement of exhaled CO2
tension combined with the simultaneous measurement of
exhaled volume.4 CO2 tension is plotted against exhaled
volume (Fig. 4) and displayed as the CO2 single breath
test. The airway (or anatomical) dead space can be calcu-
lated from Fowlers method and if the arterial PaCO2 tension is
known physiological and alveolar dead space can be
derived from the Bohr–Enghoff equation (Fig. 4).19 Other
parameters that may be calculated include total CO2 pro-
duction which is a useful measure of metabolic activity. The
values obtained appear to correlate well with the traditional
methods using the Douglas bag and metabolic cart.15
FAco
2 wall and a two-dimensional image of the cross-sectional
Fco2 Alveolar deadspace
FE'co2
Airway
deadspace
Exhaled volume
Fig 4 Single breath expiratory volumetric capnogram. VDphys/Vt=
(PaCO2
PE0CO2 )/PaCO2 ; VDalv/Vt =VDphys/Vt
VDaw/Vt.
61
Measurements of dead space have been shown to have an
increasing number of uses in the ICU. In ARDS an increased
physiological dead space has been reported to be an inde-
pendent predictor of mortality.26 The mechanism for this
association is unclear and may reflect that a high dead space
is a marker of more extensive endothelial and vascular
injury. However, increased intra-pulmonary shunt influ-
ences the measurement of the Bohr–Enghoff dead space
as the shunted pulmonary venous blood which carries
more CO2 is mixed with the arterial blood causing an
increased arterial Pco2. The association of dead space
and mortality in ARDS may be explained by an increased
apparent physiological dead space because of a more severe
shunt.8
Physiological dead space measurements may be helpful
in the optimal application of PEEP. Lung recruitment has
been associated with a reduction in dead space,39 which
may reflect a reduction in intra-pulmonary shunt. The appli-
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cation of PEEP which causes over-distension and impairs
regional pulmonary blood flow would be expected to
increase alveolar dead space.19 Volumetric capnography
has also been helpful in the diagnosis of pulmonary embo-
lism, which is associated with a large increase in alveolar
dead space that dramatically improves following reperfu-
sion after thrombolytic treatment.40
Assessment of lung recruitment
An improvement in arterial oxygen tension is highly pre-
dictive of recruitment as confirmed by CT scan32 although
it is non-specific and blood gas monitoring alone will not
reveal recruitment occurring during tidal breathing or lung
over-distension. An effective recruitment manoeuvre will be
expected to result in a significant improvement in the mea-
sured static compliance. Dynamic measurements that may
identify recruitment include assessment of the volume-
dependent change in compliance (see above). CT scanning
is considered the current gold standard for assessment of
regional distribution of ventilation and for identifying
recruitment but cannot be readily performed at the bedside.
Electrical impedance tomography is a new non-invasive
technique that allows inference of regional differences in
lung ventilation (both dependent collapse and hyperinfla-
tion) from the measurement of electrical potentials on the
chest wall. A series of electrodes are applied to the chest
distribution of thoracic impedance obtained. The changes
in impedance are assessed dynamically during tidal breath-
ing. Initial experience with this technique is promising and it
may prove to be a useful way of optimizing ventilator set-
tings to avoid VILI at the bedside.41
Automation of ventilator setting
Some ventilators are now able to offer modes of
ventilatory support where various parameters are adjusted
automatically according to the ventilator’s ability to
 Macnaughton
monitor lung performance. Adaptive support ventilation
(Hamilton Medical, Bonaduz, Switzerland) is a fully
automated mode which ensures that the desired minute
volume set by the clinician is delivered either as manda-
tory pressure-controlled breaths or spontaneous pressure-
supported breaths according to the patient’s underlying
respiratory effort. From continuous monitoring of dynamic
lung mechanics by the least squares method, the ventilator
adjusts the inspiratory pressures automatically in order to
obtain the optimal combination of ventilatory frequency and
tidal volume which achieves the target minute ventilation.
The algorithm includes a lung protective strategy, which
prevents high tidal volumes and airway pressures above
35 cm H2O. The expiratory time constant (RCe) is moni-
tored and used to adjust the time for expiration in order to
minimize the risk of PEEPi. The only parameters set by the
clinician during ASV are the minute ventilation, F IO2 and
PEEP. Minute ventilation is entered as the percentage
predicted alveolar ventilation based on ideal body weight.
Initial experience with ASV suggests that fewer ventilator
manipulations are required and that weaning may be
achieved more rapidly than with conventional ventilation
after uncomplicated cardiac surgery.29 36 37
Smart Care (Drager Medical, Lübeck, Germany) is a
computer-driven system that manages pressure support ven-
tilation over a prolonged period. The level of pressure sup-
port is automatically adjusted with the aim of weaning the
amount of support whenever possible. Using the measured
ventilatory frequency, tidal volume and end tidal CO2 ten-
sion, the pressure support is regularly adjusted to maintain
the patient in a ‘comfort zone’. While the patient remains
in the comfort zone, the knowledge-based weaning system
will assess the response to a reduction in the level of pres-
sure support. Early results with this mode have reported that
weaning is more rapid than compared with conventional
protocol-directed weaning.6 17
Conclusion
The monitoring capability of ICU ventilators is increasing in
complexity. Accurate assessment of lung mechanics allows
the clinician to choose ventilator settings that maximize
lung recruitment and prevent over-distension thereby mini-
mizing the risk of adverse effects. Some ventilators are now
able to automatically adjust ventilator settings according
to measurements of lung mechanics. There is likely to be
an increasing development of such knowledge-based sys-
tems with the aim of ensuring that patients receive the opti-
mal mode of mechanical ventilation which minimizes the
risk of ventilator-induced lung and ensures that weaning
occurs as rapidly as possible.
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