Intensive Care Med (1992) 18:193-201
IntensiveCare
Review article
Breathing pattern analysis
M.J. Tobin
LoyolaUniversityof Chicago Stritch School of Medicine, Program Director, Division of Pulmonary and Critical Care Medicine,
Edward Hines Veterans Affairs Hospital, Hines, IL 60141, USA
Received: 20 October 1991; accepted: 7 April 1992
Clinical examination of the pattern of breathing has gen-
erally consisted of counting the respiratory rate over a 15-
to 60-s period, noting abnormally deep or shallow respi-
rations, and documenting well-known patterns such as
Cheyne-Stokes or Kussmaul's breathing. In recent years,
it has been recognized increasingly that a more detailed
analysis of breathing pattern can provide valuable infor-
mation regarding respiratory system performance [1]. At
the time that advances were being made in the analytical
approach to breathing pattern, improvements were occur-
ring simultaneaously in the instrumentation used to re-
cord ventilation, especially in the non-intubated patient
[2]. In this article, I will review the methods that can be
used to record and analyze the pattern of breathing, and
the usefulness of this approach as an investigative tool in
the critical care setting.
Techniques of measurement
Visual inspection
Clinicians usually measure respiratory frequency by ob-
serving chest wall motion over 15 s and multiplying the
resulting value by 4. Using this approach, an error of 4
or more breaths/min may easily occur - a rather large
error for a parameter that is normally 1 6 - 2 0 b r e a t h s /
min. Despite the simplicity of the measurement, bedside
assessment of respiratory frequency is often inaccurate.
In one study, 34% of nurses' recordings of respiratory
frequencies deviated by more than 20% from the true val-
ue [3]. Thus, underappreciation of the clinical impor-
tance of respiratory frequency may be due partly to inac-
curacies in its measurement. Furthermore, the discon-
tinuous nature of bedside measurements may miss sud-
den changes in critically ill patients. Assessment of tidal
volume is also usually part of bedside examination, and
clinicians commonly comment on the depth or shallow-
ness of breathing. However, in a study conducted in criti-
cally ill patients, Semmes et al. [4] noted a very poor cor-
Medicine
9 Springer-Verlag1992
relation between subjective estimations of tidal volume
made by ICU personnel and objective measurements. Of
concern was the widespread tendency to overestimate tid-
al volume, which could be particularly dangerous in pa-
tients who have low tidal volumes.
Direct measurement
In the intubated patient, it is easy to directly measure ven-
tilation by attaching a spirometer or pneumotachograph
to the patient's endotracheal tube. The prototype
pneumotachograph, the Fleisch instrument, presents a
problem in this setting because condensation of moist
gases and mucus can easily clog the narrow metal tubes
within the instrument, and thus, alter resistance and pro-
duce inaccurate results. The development of newer vari-
able-orifice pneumotachographs will hopefully diminish
this problem. In the non-intubated patient, problems
arise in attempting to measure ventilation with a spiro-
meter or pneumotachograph because critically ill patients
have a low tolerance of devices that require a direct con-
nection to the patient's airway. In addition, several inves-
tigators [5-7] have shown that use of a mouthpiece and
nose clips produces spurious alterations in breathing pat-
tern, causing tidal volume to increase and respiratory fre-
quency to decrease. Although most of the studies demon-
strating the alteration in breathing pattern with the use of
a mouthpiece and noseclips have been conducted in
healthy subjects during resting breathing, this effect has
also been shown in exercising subjects with a markedly el-
evated minute ventilation (75.5 1/min) [8], and in patients
with moderately severe asthma (forced expiratory volume
in 1 s, 43070 of predicted normal) [9]. In addition, Aska-
nazi et al. [6] reported that mouthpiece-induced changes
in breathing pattern were similar in critically ill patients
as in healthy subjects, although supporting data were not
included in their report. As a result of these problems
with a mouthpiece and nose clips, several devices have
been developed to measure ventilation indirectly.
194
Impedance pneumography
Impedance pneumography is probably the technique
most often used to non-invasively monitor breathing pat-
tern. Two standard electrocardiographic electrodes placed
on the chest wall serve both to pass an alternating current
through the chest between the electrodes and to return a
voltage for calculation of impedance [6]. The resulting
waveform is qualitatively similar to that obtained with
spirometry [11]. However, the instrument cannot be cali-
brated to obtain quantitative volume measurements [2],
and measurement of respiratory frequency may even be
inaccurate [10].
Mercury-in-silastic strain gauges
This transducer consists of rubber tubes filled with mer-
cury which are wrapped around the chest [2]. Changes in
the length and width of the mercury columns alter their
resistance. These mercury columns form part of a bal-
anced Wheatstone bridge. Variation in electrical resis-
tance alters the balance of the bridge, and these changes
are amplified and recorded. Provided that there is no
change in body posture, this technique can provide a rea-
sonably accurate measurement of tidal volume.
Magnetometers
Magnetometers measure changes in the antero-posterior
diameters of the rib cage (RC) and abdomen (Ab) during
respiration [12]. An alternating current in an exciter coil
generates a magnetic field in a receiver coil placed on the
opposite body surface. The signals from the RC and Ab
are electronically summed, and when calibrated, they
provide a very accurate measurement of tidal volume.
This technique has proven to be an extremely valuable re-
search tool and has been widely employed in the study of
respiratory muscle function [13-15]. The major limita-
tion of magnetometers is that relatively small changes in
body position alter the antero-posterior diameter with re-
sulting loss of calibration and inaccurate volumetric mea-
surements.
Respiratory inductive plethysmography (RIP)
The RIP is the most widely accepted method of measur-
ing ventilation in a non-invasive and quantitative manner.
The transducers consist of two coils of insulated wire
sewn onto bands placed around the RC and Ab (Fig. 1).
The coils are connected to a small oscillator module that
puts out frequency-modulated signals that are propor-
tional to alterations in the self-inductance of the coil. The
self-inductance of the coil, and so the frequencies of its
oscillator, is proportional to the cross-sectional area en-
closed by the coil. These signals are sent to a demodula-
tor/calibrator unit which converts the signal into a pro-
portional voltage that can be amplified and recorded.
Calibration of the RIP is based on the assumption of
Konno and Mead [/6] that the respiratory system can be
considered as a simple physical system with two moving
parts, the RC and Ab. Consequently, volume measured at
the mouth is equivalent to the sum of volume change of
the RC and Ab. This concept of two degrees of freedom
f
Fig. 1. Transducer bands of the respiratory inductive plethysmograph
(RIP) placed around the rib cage and abdomen. From Tobin MJ [23]
forms the basis of the various techniques that can be used
to calibrate the RIP - isovolume, least-squares, and mul-
tiple linear regression techniques.
The isovolume calibration technique requires that the
subject voluntarily closes his/her glottis and, at a con-
stant lung volume, moves air back and forth between the
RC and Ab, without pressurizing thoracic gas volume
[16]. Since the volume lost by one compartment is gained
by the other, the amplitude of their signals must be made
equal by the operator. The RC and Ab signals are then
added to produce a sum signal, and while the subject
breathes from a spirometer the operator adjusts the sum
signal to match that of the spirometer. The difficulty that
many subjects have in performing an isovolume maneu-
ver led to the development of other calibration techniques
that could be performed during natural breathing. The
least squares calibration technique requires recordings of
spirometry, RC and Ab signals in two postures, taking ad-
vantage of the change in compartmental contribution to
tidal volume that occurs with change in body posture [/7,
18]. The RC/spirometer and Ab/spirometer ratios from
the breaths in the two postures are measured, and then
cast as coordinate pairs on an X-Y plot of RC/spirometer
against Ab/spirometer, and a least-squares regression line
is fitted through the points. The reciprocals of the inter-
cepts of this line are taken as the calibration factors of the
RC and Ab transducers. Although the least-squares tech-
nique is probably the most robust method of calibration
[/7-19], it can be quite tedious to perform, especially in
critically ill patients. The multiple linear regression tech-
nique avoids the need for variation in body posture [20],
and is based on the normal variation in compartmental
contribution during tidal breathing [21]. During the ini-
tial part of inspiration, volume change is produced pre-
dominantly by Ab displacement [22]. The contribution of
the RC progressively increases so that at the end of inspi-
ration volume change is predominantly due to RC mo-
tion. Using a computer to sample the signals (at 25 Hz)
produced by the spirometer, RC transducer and Ab trans-
ducer will field a matrix of 30 to 40 equations in two un-
knowns with the points from a single breath. Using a se-

ries of breaths in a single posture, the RC and Ab calibra-
tion factors can be computed. Recently, Sackner et al.
[23] developed a modification of the single posture tech-
nique that permits calibration of the RIP without the use
of an external spirometer or pneumotachograph. Em-
ploying this calibration technique, the RIP can provide
accurate measurements of respiratory timing and RC-Ab
coordination, and reasonably accurate measurements of
relative changes in tidal volume.
Analysis
Volume and time components
In resting healthy subjects, minute ventilation is about
6 l/rain [24]. Since PaCO2 is determined by the relation-
ship between alveolar ventilation and COa production, a
high minute ventilation in the presence of hypercapnia in-
dicates the presence of increased deadspace ventilation
and/or increased CO2 production [25]. Conversely,
hypercapnia associated with a low minute ventilation
should arouse suspicion of decreased respiratory drive,
structural abnormality of the thoracic cage or respiratory
muscle dysfunction. While a minute ventilation of less
than 101/min is commonly used as a predictor of wean-
ing outcome [26], one should not rely on this criterion
since it is associated with a high rate of false-positive and
false-negative results [27, 28].
The measurement of minute ventilation should be
partitioned into its respiratory frequency and tidal vol-
ume components. In healthy subjects, respiratory fre-
quency is approximately 17 breaths/min and tidal volume
is approximately 0.401 [24]. An elevated frequency is of-
ten the earliest sign of impending respiratory disaster [29,
30], and the degree of elevation is proportional to the se-
verity of the underlying disease [31]. In patients being
discharged from an ICU, tachypnea was more common in
patients who subsequently required readmission or died
unexpectedly [32]. In a recent study of patients who had
undergone a cardiopulmonary arrest, Schein et aI. [33]
found that 53~ of the patients had documented deterio-
ration in respiratory function in the 8 h preceding the ar-
rest. Of interest, respiratory frequency was elevated in the
majority of patients - mean, 29+ 1 (SE) breaths/min -
while other routine laboratory tests showed no consistent
abnormalities. The observation that detection of
tachypnea did not result in changes in patient manage-
ment (in an effort to prevent an arrest) led the authors to
surmise that physicians do not fully appreciate the clini-
cal importance of tachypnea.
Patients who fail a trial of weaning from mechanical
ventilation commonly display an elevated respiratory fre-
quency (f) and a low tidal volume (VT) [34]. These two
measurements can be combined to produce an index of
rapid shallow breathing, viz., the f/V T ratio. In a recent
prospective study of patients being weaned from mechan-
ical ventilation, the f/V T ratio was superior to conven-
tional predictors of weaning outcome [28]. In this study,
respiratory frequency and tidal volume were measured
with a spirometer attached to the patient's endotracheal
195
tube while he/she breathed room air for one minute. Of
the patients who had an f/V T value greater than 100
breaths/min/1, 95~ failed a weaning trial, whereas 80~
of the patients with lower f/VT values were successfully
weaned (Fig. 2). As a method of assessing pulmonary
performance in critically ill patients, the f/V T ratio has a
number of attractive features; it is easy to measure, it is
independent of the patient's effort and cooperation, it
appears to be quite accurate in predicting the ability to
sustain ventilation, and fortuitously, it has a "rounded
off" threshold value (100) that is easy to remember.
The mechanism of rapid shallow breathing is un-
known. Roussos [35] has suggested that afferent activity
arising in fatiguing respiratory muscles may impinge on
the respiratory centers and produce alterations in the
breathing pattern. In support of such an occurrence,
Gallagher et al. [36] observed rapid shallow breathing in
healthy volunteers in the period immediately following
the induction of inspiratory muscle fatigue by resistive
loading. Since minute ventilation was markedly elevated
after resistive loading, they employed CO 2 rebreathing to
achieve a similarly elevated minute ventilation during the
control recordings prior to loading. However, such an ap-
proach may not be valid since several investigators have
shown that breathing pattern differs substantially under
non-steady state conditions depending on the stimulus
used to augment ventilation [37-40]. To avoid this con-
founding effect, Mador and I [41] recently examined the
pattern of breathing before and after inducing respiratory
muscle fatigue, and found that fatigue did not produce
rapid shallow breathing during either unstimulated
breathing or CO2 rebreathing. In complementary stud-
ies, Mador and Acevedo [42, 431 observed rapid but not
shallow breathing when fatigue was combined with an in-
creased load. Further investigations are required to deter-
80-
120 / 100
i 60 - /~ 80 9 Failure
r~ Success
~' 40 9 ""= ql
~. 2o
is f [] ~aa
0.0 0.2 0 0.6 0 10 1.2
Tidal Volume (liters)
Fig. 2. Isopleths for the ratio of breathing frequency to tidal volume,
representing different degrees of rapid shallow breathing. For the pa-
tients indicated by the points to the left of the isopleth representing 100
breaths/rain/I, the likelihood that a weaning trial would fail was 95o70,
whereas for the patients indicated by the points to the right of this
isopleth, the likelihood of a successful weaning outcome was 80%. The
hyperbola represents a minute ventilation of 101/min, a criterion com-
monly used to predict weaning outcome; apparently, this criterion was
of little value in discriminating between weaned patients (open sym-
bols) and the patients in whom weaning failed (solid symbols). From
Yang KL and Tobin MJ [28]
196
mine the mechanisms of this major disturbance in
breathing pattern.
A more detailed approach to breathing pattern analy-
sis can provide additional information regarding the re-
spiratory control system. In contrast to the traditional ap-
proach where minute ventilation (~rE) is analyzed in
terms of tidal volume (VT) and respiratory frequency (f),
i.e.,
VE = V T X f
Barcroft and Margaria, in 1931, proposed that minute
ventilation should be analyzed in terms of "(1) the dura-
tion of the phases of respiration... (2) upon the rates at
which air is given in and out during the phases" [44]. This
analytical approach lay dormant for the next 40 years un-
til the publication of some elegant studies by Clark and
yon Euler in 1972 [45]. This work was later extended by
Milic-Emili and Grunstein [46] who proposed a further
mathematical analysis of the breathing cycle. The tradi-
tional equation of minute ventilation (Eq. 1) is rear-
ranged, since respiratory frequency is equal to 60 divided
by the time of a total respiratory cycle (TToT) or single
breath.
~rE = V T X 6 0 / T T o T
Conceptually, 60 can be deleted and the equation reduced
to
~rE = VT • I/TToT
Dividing VT by inspiratory time (T 0 while multiplying
1/TToT by T~ gives
~rE = VT/T I • T (4)
The first parameter, VT/TI, has been termed mean in-
spiratory flow rate, and the second parameter, TI/TToT,
has been called fractional inspiratory time (Fig. 3).
VT/TI has been widely employed as a measure of re-
spiratory drive. The neurogenic basis of doing so has
been demonstrated by a number of investigators (particu-
larly von Euler and Cohen and co-workers). Once inspira-
tion has begun, changes in pulmonary afferent activity,
/ \ I/
I
!'\ II /
. _ i~ - i
Ab
Max. Arnpl.
I I
o 5
such as that produced by lung inflation, paralysis or air-
way occlusion, produce no appreciable change in the
slope of integrated phrenic nerve activity [l, 46-48].
VT/T~, which is the mechanical transformation of this
neural activity, has been shown to be related to standard
indices of respiratory center output, such as Po.1 and the
ventilatory response to hypercapnia [49-51]. An in-
herent disadvantage of VT/TI is that, unlike P0.~, it may
underestimate respiratory drive in the presence of marked
(1)
abnormalities in respiratory system mechanics. However,
an elevated VT/T~ in this situation reflects elevated respi-
ratory drive, albeit it may be underestimated. For exam-
ple, in a study of patients who failed a trial of weaning
from mechanical ventilation, an increase in VT/TI was
observed between the beginning and end of the weaning
trial indicating that an impairment in respiratory center
output was not the primary cause of ventilatory failure in
these patients [34] (Fig. 4).
Fractional inspiratory time, TI/TTOT, indicates the re-
lationship between inspiration and expiration and pro-
vides a crude measure of the degree of airway obstruction
[52]. Since the respiratory muscles are normally active
only during inspiration, TI/TTOT has also been termed
the duty cycle of the respiratory system and the level of
(2) stress placed on the respiratory muscles is proportional to
TI/TTo T. Indeed, TI/TToT and the ratio of mean
transdiaphragmatic pressure (Pdi) per breath/maximum
static P~ (i.e., P J P ~ m a x ) are equally important deter-
(3) minants of diaphragmatic fatigue [53]. The product of
these ratios is termed the diaphragmatic tension-time in-
dex (TTai) and once a critical value of 0.15 is reached,
diaphragmatic fatigue is likely to ensue [53]. When re-
porting measurements of tension-time index, it is impor-
tant to indicate whether it has been computed from vol-
ume/flow or pressure recordings, as values calculated
from pressure tracings will be considerably higher than
the former [54]. Despite the evidence that TI/TToT is a
major determinant of respiratory muscle endurance in ex-
perimental volunteers, and that a reduction in TI/TToT is
a useful strategy for decreasing the risk o f fatigue, in clin-
ical reality patients rarely display large changes in
TI/TTOT [30, 39].
Fig. 3. Schematic recording of the respira-
tory cycle obtained with a respiratory in-
ductive plethysmograph. The sum signal
represents tidal volume (VT), which is de-
\ / \ rived from the algebraic sum of the rib
cage (RC) and abdominal (Ab) excursions.
"~ End-K~mtory Level T I = inspiratory time; T E = expiratory time;
TTOT = time of a total breath;
VT/T I = mean inspiratory flow rate. Altera-
tions in the end-expiratory level represent
changes in functional residual capacity,
provided movement artifact is absent. Max-
imum amplitude is the trough-to-peak am-
plitude of the RC and Ab excursion, irre-
spective of their phase relationship to the
sum (tidal volume) signal, Their arithmetic
sum, designated maximum compartmental
amplitude (MCA), is equivalent to the al-
I
l0 gebraic sum signal (VT) when the RC and
Ab move in phase. From Tobin MJ [76]
 197

500- 800-

~e
~ 400
600 -
"E 300 |
9 _I_
1-
, II
200
i p <0.01
O= >
Start End
Fig. 4. Measurements of mean inspiratoryflow (VT/TI),an index of re-
spiratory drive,in 7 patients who failed a trial of weaning from mechan-
ical ventilation. Note that an increase in VT/TI was observed in each
patient betweenthe beginning and end of the weaningtrial. From Tobin
MJ et al [34]

Compared with traditional methods of assessing the v Eucapoia . Hypercapnia

respiratory control system, the reproducibility of breath- (n = 1 6 ) (n = 12)
ing pattern measurements is very appealing. The enor- Fig. S. Mean inspiratory flow (VT/TI), an index of respiratory drive,
mous inter- and intra-individual variability of the ven- during restingbreathing in patients with chronic obstructivepulmonary
tilatory and mouth occlusion pressure responses to hyper- disease. The shaded area representsthe 95 per cent confidencelimits of
capnia and hypoxia makes it difficult to characterize the VT/T~in healthy subjects. From Tobin MJ [77]
response of any single individual as abnormal [55, 56].
Between subjects, the coefficient of variation for the ven-
tilatory responses to chemical stimulation is approxi-
the various respiratory muscles [2, 13-15]. In their origi-
mately 50% [55]. Within subjects, the coefficient o f vari-
nal paper, Konno and Mead [16] demonstrated the value
ation is 20~ when the ventilatory response is measured
of plotting motion of the RC and Ab on a X-Y plot. This
over a 2 h period, and this degree of variation increases
allows simultaneous assessment of the relative motion of
6-fold when repeated on different days [56]. The enor-
the two compartments, and by calibrating motion for vol-
mous variability of these indices in healthy subjects
ume change it is possible to determine compartmental
makes it difficult to characterize the response o f any sin-
contribution to tidal volume and the degree of breath-
gle individual as abnormal, and limits their value for as-
to-breath variation in this contribution (Fig. 6). During
sessing the response to an experimental intervention [55].
normal breathing both RC and Ab expand on inspiration
In contrast, the inter-individual coefficient o f variation
and decrease back to the resting position during expira-
for VT/T I and T I / T ~ T in healthy subjects is 22O/o and
tion. Since the rate of excursion is virtually the same for
8%, respectively, if measured non-obtrusively [57]. When
t h e two compartments, an X-Y plot of RC-Ab motion
repeated on different days, the intra-individual coeffi-
shows the formation of a closed or a very slightly open
cient of variation of VT/T I and Ti/Ta-or are 9~ and 3%,
loop. Abnormal motion can be separated into three ma-
respectively, compared with 40% for the ventilatory re-
jor types: (1) asynchrony, in which the two compartments
sponse to hypercapnia [57]. This degree o f reproducibility
continue to move in the same overall direction, but the
allows the construction of a relatively narrow normal
rate of motion differs causing a widened loop to form on
range for the breathing pattern components, permitting
the X-Y plot; (2) paradox, in which one compartment
the detection of abnormalities in individual patients, un-
moves in an opposite direction to the overall tidal volume
like the experience with conventional techniques [55]. For
signal, resulting in a negative slope on the X-Y plot; (3)
example, although VT/T I is commonly considered an in-
an increase in the breath-to-breath variation in the rela-
sensitive index of respiratory drive in patients with abnor-
tive contribution of the RC and Ab to tidal volume, repre-
mal lung mechanics, in a study of patients with COPD
senting recruitment and derecruitment of the accessory-
it was elevated above the normal 95% confidence limits
intercostal muscles and diaphragm [59, 60].
in 71% of the patients [52] (Fig. 5).
Paradoxical motion of the RC is a characteristic find-
ing in patients with cervical cord lesions, while patients
Rib cage-abdominal motion
with diaphragmatic paralysis display abdominal paradox.
Although investigations of chest wall motion extend back Recently, there has been considerable interest in the study
to the last century [58], it is only in the last twenty-five of RC-Ab motion in acutely-ill patients who do not have
years, following the landmark study of Konno and Mead diseases that primarily involve the chest wall. Using un-
[16], that this approach has been widely employed as a calibrated magnetometers, Ashutosh, Gilbert, and col-
means of investigating the activity and coordination of leagues [61, 62] noted that patients displaying asynchro-
198
4oo]-
=If___4
2 BeG
,,i,o.,,
-0.25L~ + 0.25L
-L-0.25L ~ -0.25L "a-'-O.2~'L
Mechanical Weaning Trial
Ventilation Start End
Fig. 6. Analog tracing of the s u m (VT) , rib-cage (RC), and abdominal
(Ab) volume signals during mechanical ventilation and at the beginning
and end of a weaning trial in a patient with an unsuccessful weaning
outcome. The terminal portion of the preceding breath and the initia-
tion of the subsequent breath are also shown. For clarity, the baselines
of the individual analog signals have been adjusted arbitrarily to pro-
vide visual separation of the signals. The respective Konno-Mead plots
of the RC-Ab relationship are displayed below each of the breaths. Dur-
ing mechanical ventilation, there is some Ab paradox, which increases
immediately upon discontinuation of the ventilator. There is no pro-
gression in the extent of abnormal RC-Ab motion from the beginning
to the end of the weaning trial 24 rain later. From Tobin MJ et al [65]
Pm Pm
Baseline 30% max 60% max
s Ab motion does not signify muscle fatigue [65]. Since
"6
> tory muscle fatigue (by definition), ventilator dependent
o 1.5
CZ:
I
t 0.5 : I ;
Ab Volume (I)
Fig. 7. Konno-Mead plots of rib cage (RC)-abdominal (Ab) motion
from a subject during resting breathing and while breathing against a
resistive inspiratory load of sufficient magnitude to require the genera-
tion of 30% and 60% of maximum mouth pressure (Pmmax). At 30%
of PmmaX, a loop forms, indicating RC-Ab asynchrony, and some Ab
paradox is also evident. At 60% of PmmaX, the degree of Ab paradox
increases further, as indicated by the leftward shift in the plot. The pres-
ence of abnormal RC-Ab motion at 30~ of Pmmax is of significance,
since this level of pressure can be sustained indefinitely without the de-
velopment of respiratory muscle fatigue. From Tobin MJ et al [66]
nous RC-Ab movements had an increased risk of ven-
tilatory failure necessitating mechanical ventilation [62]
and a poor prognosis [61]. Subsequently, investigators at
McGilI University suggested that Ab paradox is virtually
pathognomonic of diaphragmatic fatigue [63] if dia-
phragmatic paralysis and inversion are excluded [59, 60].
This interpretation was largely based on a study of 12 pa-
tients exhibiting difficulties during weaning from me-
chanical ventilation [59]. Seven of the patients has a pow-
er spectral shift in their diaphragmatic electromyogram
(EMG) signal that was interpreted as indicating fatigue.
Of these 7 patients 6 has Ab paradox, whereas this was
absent in the 5 patients without EMG changes. Electrical
interference prohibited the employment of their magne-
tometers, and paradoxical motion was only characterized
by clinical examination. In addition, a shift in the EMG
power spectrum has not been shown to bear a relation-
ship to the form of fatigue that is physiologically impor-
tant, viz., low-frequency fatigue, and its physiological ba-
sis remains unknown [64]. Moreover, no attempt was
made to separate the effect of work of breathing, i.e.,
load, from muscle fatigue in these patients [59].
In a departure from the descriptive character of most
previous studies employing Konno-Mead plots, Tobin et
al. [65, 66] computed several indices that provided quan-
titative assessment of the amount of asynchrony, paradox
and breath-to-breath variability in compartmental contri-
bution to tidal volume. By calculating these indices from
a series of breaths at fixed periods in time, it was possible
to obtain a measure of the degree of inter- and intrasub-
ject variability and thereby avoid the bias that might re-
suit with subjective selection of a few breaths. In a study
conducted in healthy subjects breathing against resistive
loads and using an experimental design that permitted
the separation of the effect of loading from fatigue, they
found that fatigue was neither necessary nor sufficient to
induce asynchrony, paradox or increased variability in
RC-Ab motion [66] (Fig. 7). In contrast, respiratory load-
ing was sufficient to induce abnormal motion.
Observations in patients being weaned from mechani-
cal ventilation also support the view that abnormal RC-
ventilation cannot be sustained in the presence of respira-
patients who display Ab paradox should inevitably devel-
op ventilatory failure if ventilator support is discontin-
ued. However, Tobin et al. [65] observed considerable
overlap in the degree of Ab paradox in patients who were
successfully weaned and in those who failed a weaning
trial (Fig. 8). Another index of RC-Ab motion termed
maximum compartmental amplitude-to-tidal volume ra-
tio (MCA/VT) (Fig. 3) discriminated between the two
groups of patients. The apparent superiority of M C A /
V T ratio over other indices may be related to the fact it
is the only index that takes both asynchrony and paradox
of both the RC and Ab into account. Patients who failed
the weaning trial also displayed considerable breath-
to-breath fluctuation in the relative contribution of the
RC and Ab to tidal volume, with the result that the extent
of abnormal motion tended to be divided between the
two compartments. Krieger and Ershowsky [67] also re-
ported that an elevated MCA/VT ratio and increased
variability in compartmental contribution to tidal volume
were helpful in predicting weaning outcome. Accordingly,
one can conclude that while abnormal RC-Ab motion is
not due to fatigue per se, monitoring such motion can be
clinically useful since it provides a non-invasive reflection
of the balance between respiratory load and the capacity
of the respiratory muscles to meet that load.
 199

100' P E E P at w h i c h e n d - e x p i r a t o r y lung v o l u m e increased,

r
t h e y o b t a i n e d a r e m a r k a b l y close estimate o f the p a t i e n t ' s
=80 o r i g i n a l level o f a u t o - P E E P . A n attractive feature o f this
L.
L. t e c h n i q u e is t h a t it does n o t d i s t u r b expiration, unlike t h e
=6o occlusive technique, in which f o r e s h o r t e n i n g o f expirato-
r
o r y t i m e is u n a v o i d a b l e [73]. E x t e r n a l P E E P has recently
,,..,40 b e e n a d v o c a t e d as a m e a n s o f decreasing w o r k o f b r e a t h -
=:
r
ing in p a t i e n t s w i t h a u t o - P E E P [70, 74, 75]. I f external
P E E P is used for this purpose, m o n i t o r i n g t h e end-expi-
I:., r a t o r y level offers promise, p a r t i c u l a r l y in s p o n t a n e o u s l y
b r e a t h i n g patients, as a m e a n s o f d e t e r m i n i n g if the level
WS WF WS WF WS WF o f external P E E P r e m a i n s o p t i m a l , especially since t h e
Ab Paradox MCAN T R C N T Variability level o f a u t o - P E E P varies over t i m e [70]. I n a d d i t i o n , this
(> 10%) ( > 1,18) (SD > 10%) t e c h n i q u e m a y serve as a simple a n d convenient test o f
Fig. 8. The frequency of significant abnormalities of rib cage-abdomi- a i r f l o w limitation: in flow-limited patients, e n d - e x p i r a t o -
nal in patients who were successfully weaned (WS) and in patients who r y lung v o l u m e s h o u l d r e m a i n u n c h a n g e d until the criti-
failed a weaning trial (WF). Significant abdominal (Ab) paradox was cal level o f external P E E P is exceeded, whereas in p a -
considered present when paradoxic volume was > 10% of the total Ab tients w i t h o u t flow l i m i t a t i o n , a progressive increase in
volume excursion (both in and out phase). The maximum compartmen- lung v o l u m e ( a n d p e a k airway pressures) s h o u l d occur,
tal amplitude to tidal volume ratio (MCA/VT) (see derivation in Fig. 3)
starting with even the smallest i n c r e m e n t s in external
was considered significantly increased when it exceeded 1.18. A signifi-
cant increase in the breath-to-breath variabilityin the relative contribu- P E E P [73].
tion of the rib cage (RC) and Ab to tidal volume (VT) was considered In conclusion, b r e a t h i n g p a t t e r n analysis serves as a
present when the standard deviation (SD) of the RC/V T ratio exceeded very p o w e r f u l research t o o l in investigating the n e u r o -
10%. Significant differences were observed between the groups of pa- m u s c u l a r c o n t r o l o f b r e a t h i n g , and, in clinical practice, it
tients in the occurrence of an increased MCA/V T ratio (t7< 0.001) and is p r o v i n g to b e a h e l p f u l m e a n s o f m o n i t o r i n g respirato-
increased variability of the RC/V x ratio (p<0.05), but not for in- r y p e r f o r m a n c e in critically ill patients.
creased Ab paradox. (Based on data published in Tobin MJ et al [65]

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Professor
M.J. Tobin, MD
Loyola University of Chicago
Stritch School of Medicine
Division of Pulmonary and
Critical Care Medicine
Edward Hines Veterans Affairs Hospital
Hines, IL 60141
USA