[Determination of intrinsic PEEP during mechanical ventilation. Validation of a new optional method of measurement provided by the EVITA mechanical ventilator].

Intrinsic positive end-expiratory pressure (PEEPi) occurring during mechanical ventilation depends on expiratory time constants, expiratory volume and expiration time as well as on external flow resistance (tubes, valves, etc.). It is not routinely determined in mechanically ventilated patients, but it is necessary to optimize respirator settings. The aim of the present study was the validation of an automated PEEPi determination method implemented in the respirator EVITA (Drägerwerke, Lübeck) in mechanically ventilated patients with acute lung failure. PATIENTS. The method was validated in ten sedated, myorelaxed patients with respiratory insufficiency of different etiologies (five with restrictive, and five with obstructive pulmonary disease). PEEPi was determined using the volume constant ventilatory mode at ZEEP or at an external PEEP of 5 as well as 10 cm H2O. METHOD. PEEPi was first determined with the automated method implemented in the EVITA (five measurements at each end-expiratory pressure level; PEEPEvita). Steady-state was attained between each measurement. These values were compared to the results obtained with end-expiratory occlusion (external, computer-controlled valve in the inspiratory limb of the circuit) at the respective pressure levels (PEEPEEO). The average of five measurements at each PEEP level with each method was defined as PEEPi for the particular ventilatory situation. Gas flow was measured at the proximal end of the endotracheal tube with a heated pneumotachometer (Fleisch no. 2, Fleisch, Lausanne, Switzerland) and a differential pressure transducer. Tracheal pressure was determined in the same position with a further differential pressure transducer (Dr. Fenyves & Gut, Basel, Switzerland). After A/D conversion, data were sampled with a frequency of 20 Hz and processing as well as for control of the occlusion valve was self-programmed. For the statistical analysis we used the Mann-Whitney U-test or Wilcoxon signed-ranks test; a P value less than 0.05 was considered significant. RESULTS. At the given respiratory setting and without PEEP patients with obstructive lung disease had a higher PEEPi (median: 6.4 cm H2O; range: 5.0-9.6 cm H2O) than those with restrictive pulmonary disease (median: 2.3 cm H2O; range: 0.8-3.0 cm H2O) (P < 0.05). Increasing external PEEP to 5 or 10 cm H2O significantly decreased the pressure difference between PEEPi and external PEEP (P < 0.05), but was unable to eliminate it completely. There was no statistically significant difference between PEEPEEO and PEEPEvita (P = 0.43; Wilcoxon signed-ranks tests). Regression analysis showed a highly significant correlation between PEEPEEO and PEEPEvita values (r = 0.985, P < 0.001; y = 1.03 x-0.18). DISCUSSION. PEEPi occurs during ventilation in patients with obstructive and restrictive lung disease. The difference between external end-expiratory pressure and PEEPi decreases with increasing external PEEP. However, PEEPi may increase with increasing external PEEP in some instances. The reason for this may be that the PEEPi determined at the proximal end of the endotracheal tube represents only a mean value of different PEEPi values of various lung regions. Increasing external PEEP only partially alters this mean value due to an effect on PEEPi values lower than external PEEP. The PEEPi values measured by the EVITA respirator compared with classical end-expiratory occlusion with an external valve were nearly identical. Unfortunately, PEEPi measurement of the EVITA can only be performed during controlled and not during assisting (PSV, BIPAP etc.) ventilation. Optimal respirator settings require a knowledge of PEEPi (i.e., adaption of external PEEP for lowering the work of breathing in COPD patients or prolongation of the expiratory phase to avoid unwanted side effects of an occult PEEPi on the circulation). Since mo