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Using the Ventilator to Probe

Physiology: Monitoring Graphics and


Lung Mechanics During Mechanical
Ventilation

Dean Hess, PhD, RRT


Massachusetts General Hospital
Boston, MA
Respiratory Care, January and February, 2005
Monitoring Respiratory Mechanics
• Pressure, flow, and volume in ventilator circuit
• Esophageal (pleural) and gastric (abdominal) pressures
• Derived measures
– Compliance
– Resistance
• Time-based graphics (waveforms)
– Pressure
– Flow
– Volume
• Loops
– Pressure volume
– Flow volume
PIP:
compliance
resistance
volume
flow
PEEP
Pressure

PEEP

time
No active breathing
Treats lung as single unit PIP

resistance
flow

Pplat
end-inspiratory
alveolar pressure

compliance
tidal volume

PEEP
Nilsestuen, Respir Care 2005; 50:202-232
Pressure (cm H2O) Volume (mL) Flow (L/min)

PIP

Lucangelo, Respir Care 2005; 50:55


Pplat = Palv;
Pplat = Transpulmonary Pressure?
+15 cm H2O
transpulmonary
pressure = 15 cm H2O

Pplat 30 cm H2O

Stiff chest wall


Pplat = Palv;
Pplat = Transpulmonary Pressure?
-15 cm H2O
transpulmonary
pressure = 45 cm H2O
PCV 20 cm H2O,
PEEP 10 cm
H2O; Pplat 30 cm
H2O

Active inspiratory effort


Pplat = Palv;
Pplat = Transpulmonary Pressure?

Pplat 30 cm H2O, Pplat 30 cm H2O, Pplat 30 cm H2O,


VCV VCV PCV

Active inspiratory effort

Risk of VILI may be different with the same Pplat


Respiratory System Compliance
tidal volume Correct for gas compression
C=
Pplat - PEEP Total PEEP

Decreased with:
• mainstem intubation • tension pneumothorax
• congestive heart failure • pleural effusion
• ARDS
• atelectasis • abdominal distension
• consolidation • chest wall edema
• fibrosis • thoracic deformity
• hyperinflation normal 100 mL/cm H O
2
ΔPeso ≈ ΔPpl

Benditt, Respir Care 2005; 50:68


Full Ventilator Support

Ccw = VT/ΔPeso
= 350 mL/5 cm H2O
= 70 mL/cm H2O
Inhalation Exhalation

positive
mm Hg
pressure
18
ventilation

10 Chest wall compliance

Inhalation Exhalation

mm Hg
spontaneous 18 Inspiratory muscle effort
breathing
10

Br J Anaesth 1976;48:474; Respir Physiol 1977;31:63; Crit Care Med


1983;11:271; Eur Respir J 1988;1:51; Chest 2002; 21:533-538
Inspiratory Resistance
PIP - Pplat
Ri =
flow
measure with 60 L/min (1 L/s)
constant flow
Increased with:
• Secretions
• Bronchospasm
• Small endotracheal tube
Normal: 5 - 10 cm H2O/L/s for intubated ventilated adults
PIP tidal volume
Crs =
Pplat - PEEP

Ppl tidal volume


Ccw =
(Peso) ∆ Peso
tidal volume
Palv CL =
(Pplat) (Pplat – PEEP) - ∆ Peso
PIP - Pplat
Ri =
flow
Pressure-Controlled Ventilation

Increasing airways resistance

Decreasing lung compliance

Lucangelo, Respir Care 2005; 50:55


Pressure-Controlled Ventilation

Lucangelo, Respir Care 2005; 50:55


No active exhalation or inspiratory effort
Treats lungs as single compartment

PIP PIP
pressure

auto PEEP
set PEEP
time
auto-PEEP of
5 cm H2O by
occlusion
technique

Leatherman, Crit Care Med 1996; 24:541


Problems with Auto-PEEP
• Increased Pplat and over-distention
– Increase work-of-breathing
– Hemodynamic effects
– Pneumothorax
• Difficulty triggering ventilator
PEEP
7 cm H2O

sensitivity sensitivity
-1 cm H2O -1 cm H2O
auto-PEEP auto-PEEP
10 cm H2O 3 cm H2O

PEEP PEEP
10 cm H2O 10 cm H2O

trigger effort = 11 cm H2O trigger effort = 4 cm H2O

Auto-PEEP should be measured with set PEEP = 0


flow Flow Waveform
inhalation

time
0
auto-PEEP

exhalation
1

0 flow
(L/s)
0.8

volume
0 (L)
30
Paw
(cm H2O)
0
20
Peso
0 (cm H2O)
estimation of missed
auto-PEEP trigger effort
Volume Volume Waveform

leak

time
1.6
normal
volume above FRC (liters)
1.2

ARDS
0.8

upper inflection
point
0.4

lower inflection
point
0

0 10 20 30 40
airway pressure (cm H2O)
Issues with PV Curves
• Requires sedation and often paralysis
• Difficult to identify “inflection points”
Harris et al, AJRCCM 2000; 161:432
• May require esophageal pressure to separate lung
from chest wall effects
Mergoni et al, AJRCCM 1997; 156:846
Ranieri et al, AJRCCM 1997; 156:1082
• Deflation limb may be more useful than inflation limb
Holzapfel et al, Crit Care Med 1983; 11:561
Hickling, AJRCCM 2001; 163:69
• Pressure-volume curves of individual lung units
unknown
Hickling, AJRCCM 1998; 158:194
Dhand, Respir Care 2005; 50:246
Summary
• Assessment of mechanics is useful in
mechanically ventilated patients: PIP, Pplat,
auto-PEEP, Ccw, Pdi
• Assessment of mechanics provides insights
into the pathophysiology of the lungs
Pressure

time

time
Flow
Who’s Watching the Patient?

Pierson, IN: Tobin, Principles and Practice of Critical Care Monitoring