JOURNAL ARTICLE
RANDOMIZED CONTROLLED TRIAL

[Variation in inspiratory gas flow in pressure support ventilation. The effect on respiratory mechanics and respiratory work]

M Sydow, K Thies, J Engel, W Golisch, H Buscher, J Zinserling, H Burchardi
Der Anaesthesist 1996, 45 (11): 1051-8
9012300

UNLABELLED: During pressure support ventilation (PSV), the timing of the breathing cycle is mainly controlled by the patient. Therefore, the delivered flow pattern during PSV might be better synchronised with the patient's demands than during volume-assisted ventilation. In several modern ventilators, inspiration is terminated when the inspiratory flow decreases to 25% of the initial peak value. However, this timing algorithm might cause premature inspiration termination if the initial peak flow is high. This could result not only in an increased risk of dyssynchronization between the patient and the ventilator, but also in reduced ventilatory support. On the other hand, a decreased peak flow might inappropriately increase the patient's inspiratory effort. The aim of our study was to evaluate the influence of the variation of the initial peak-flow rate during PSV on respiratory pattern and mechanical work of breathing.

PATIENTS: Six patients with chronic obstructive pulmonary disease (COPD) and six patients with no or minor nonobstructive lung pathology (control) were studied during PSV with different inspiratory flow rates by variations of the pressurisation time (Evita I, Drägerwerke, Lübeck, Germany). During the study period all patients were in stable circulatory conditions and in the weaning phase.

METHOD: Patients were studied in a 45 degrees semirecumbent position. Using the medium pressurization time (l s) during PSV the inspiratory pressure was individually adjusted to obtain a tidal volume of about 8 ml/kg body weight. Thereafter, measurements were performed during five pressurization times (< 0.1, 0.5, 1, 1.5, 2 s defined as T 0.1, T 0.5, T 1, T 1.5 and T 2) in random order, while maintaining the pressure support setting at the ventilator. Between each measurement steady-state was attained. Positive end-exspiratory pressure (PEEP) and FIO2 were maintained at prestudy levels and remained constant during the study period. Informed consent was obtained from each patient or his next of kin. The study protocol was approved by the ethics committee of our medical faculty. Gas flow was measured at the proximal end of the endotracheal tube with a pneumotachometer (Fleisch no. 2, Fleisch, Lausanne, Switzerland) and a differential pressure transducer. Tracheal pressure (Paw) was determined in the same position with a second differential pressure transducer (Dr. Fenyves & Gut, Basel, Switzerland). Esophageal pressure (Pes) was obtained by a nasogastric balloon-catheter (Mallinckrodt, Argyle, NY, USA) connected to a further differential pressure transducer of the same type as described above. The balloon was positioned 2-3 cm above the dome of the diaphragm. The correct balloon position was verified by an occlusion test as described elsewhere. The data were sampled after A/D conversion with a frequency of 20 Hz and processed on an IBM-compatible PC. Software for data collection and processing was self-programmed using a commercially available software program (Asyst 4.0, Asyst Software Technologies, Rochester, NY, USA). Patient's inspiratory work of breathing Wpi (mJ/l) was calculated from Pes/ volume plots according to the modified Campbell's diagram. Dynamic intrinsic PEEP (PEEPidyn) was obtained from esophageal pressure tracings relative to airway pressure as the deflection in Pes before the initiation of inspiratory flow Patient's additive work of breathing (Wadd) against ventilator system resistance was calculated directly from Paw/V tracings when Paw was lower than the pressure on the compliance curve. Two-way analysis of variance (ANOVA) was used for statistical analysis, followed by post hoc testing of the least significant difference between means for multiple comparisons. Probability values less than 0.05 were considered as significant.

RESULTS: COPD patients had significantly higher pressure support than control patients. With decreasing inspiratory flow, Wpi increased significantly in COPD patients.(ABSTRACT TRUNCATED)

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