Lisbet Niklason

Effects of inspiratory pause on CO2 elimination and arterial PCO2 in acute lung injury

A high respiratory rate associated with the use of small tidal volumes, recommended for acute lung injury (ALI), shortens time for gas diffusion in the alveoli. This may decrease CO(2) elimination. We hypothesized that a postinspiratory pause could enhance CO(2) elimination and reduce Pa(CO(2)) by reducing dead space in ALI. In 15 mechanically ventilated patients with ALI and hypercapnia, a 20% postinspiratory pause (Tp20) was applied during a period of 30 min between two ventilation periods without postinspiratory pause (Tp0). Other parameters were kept unchanged. The single breath test for CO(2) was recorded every 5 min to measure tidal CO(2) elimination (VtCO(2)), airway dead space (V(Daw)), and slope of the alveolar plateau. Pa(O(2)), Pa(CO(2)), and physiological and alveolar dead space (V(Dphys), V(Dalv)) were determined at the end of each 30-min period. The postinspiratory pause, 0.7 +/- 0.2 s, induced on average <0.5 cmH(2)O of intrinsic positive end-expiratory pressure (PEEP). During Tp20, VtCO(2) increased immediately by 28 +/- 10% (14 +/- 5 ml per breath compared with 11 +/- 4 for Tp0) and then decreased without reaching the initial value within 30 min. The addition of a postinspiratory pause significantly decreased V(Daw) by 14% and V(Dphys) by 11% with no change in V(Dalv). During Tp20, the slope of the alveolar plateau initially fell to 65 +/- 10% of baseline value and continued to decrease. Tp20 induced a 10 +/- 3% decrease in Pa(CO(2)) at 30 min (from 55 +/- 10 to 49 +/- 9 mmHg, P < 0.001) with no significant variation in Pa(O(2)). Postinspiratory pause has a significant influence on CO(2) elimination when small tidal volumes are used during mechanical ventilation for ALI.

CO2 elimination at varying inspiratory pause in acute lung injury

Previous studies have indicated that, during mechanical ventilation, an inspiratory pause enhances gas exchange. This has been attributed to prolonged time during which fresh gas of the tidal volume is present in the respiratory zone and is available for distribution in the lung periphery. The mean distribution time of inspired gas (MDT) is the mean time during which fractions of fresh gas are present in the respiratory zone. All ventilators allow setting of pause time, TP, which is a determinant of MDT. The objective of the present study was to test in patients the hypothesis that the volume of CO2 eliminated per breath, VTCO2, is correlated to the logarithm of MDT as previously found in animal models. Eleven patients with acute lung injury were studied. When TP increased from 0% to 30%, MDT increased fourfold. A change of TP from 10% to 0% reduced VTCO2 by 14%, while a change to 30% increased VTCO2 by 19%. The relationship between VTCO2 and MDT was in accordance with the logarithmic hypothesis. The change in VTCO2 reflected to equal extent changes in airway dead space and alveolar PCO2 read from the alveolar plateau of the single breath test for CO2. By varying TP, effects are observed on VTCO2, airway dead space and alveolar PCO2. These effects depend on perfusion, gas distribution and diffusion in the lung periphery, which need to be further elucidated.

Carbon dioxide rebreathing with the anaesthetic conserving device, AnaConDa®

BACKGROUND The anaesthetic conserving device (ACD) AnaConDa(®) was developed to allow the reduced use of inhaled agents by conserving exhaled agent and allowing rebreathing. Elevated has been observed in patients when using this ACD, despite tidal volume compensation for the larger apparatus dead space. The aim of the present study was to determine whether CO(2), like inhaled anaesthetics, adsorbs to the ACD during expiration and returns to a test lung during the following inspiration. METHODS The ACD was attached to an experimental test lung. Apparent dead space by the single-breath test for CO(2) and the amount of CO(2) adsorbed to the carbon filter of the ACD was measured with infrared spectrometry. RESULTS Apparent dead space was 230 ml larger using the ACD compared with a conventional heat and moisture exchanger (internal volumes 100 and 50 ml, respectively). Varying CO(2) flux to the test lung (85-375 ml min(-1)) did not change the measured dead space nor did varying respiratory rate (12-24 bpm). The ACD contained 3.3 times more CO(2) than the predicted amount present in its internal volume of 100 ml. CONCLUSIONS Our measurements show a CO(2) reservoir effect of 180 ml in excess of the ACD internal volume. This is due to adsorption of CO(2) in the ACD during expiration and return of CO(2) during the following inspiration.

Dead space and CO2 elimination related to pattern of inspiratory gas delivery in ARDS patients

IntroductionThe inspiratory flow pattern influences CO2 elimination by affecting the time the tidal volume remains resident in alveoli. This time is expressed in terms of mean distribution time (MDT), which is the time available for distribution and diffusion of inspired tidal gas within resident alveolar gas. In healthy and sick pigs, abrupt cessation of inspiratory flow (that is, high end-inspiratory flow (EIF)), enhances CO2 elimination. The objective was to test the hypothesis that effects of inspiratory gas delivery pattern on CO2 exchange can be comprehensively described from the effects of MDT and EIF in patients with acute respiratory distress syndrome (ARDS).MethodsIn a medical intensive care unit of a university hospital, ARDS patients were studied during sequences of breaths with varying inspiratory flow patterns. Patients were ventilated with a computer-controlled ventilator allowing single breaths to be modified with respect to durations of inspiratory flow and postinspiratory pause (TP), as well as the shape of the inspiratory flow wave. From the single-breath test for CO2, the volume of CO2 eliminated by each tidal breath was derived.ResultsA long MDT, caused primarily by a long TP, led to importantly enhanced CO2 elimination. So did a high EIF. Effects of MDT and EIF were comprehensively described with a simple equation. Typically, an efficient and a less-efficient pattern of inspiration could result in ± 10% variation of CO2 elimination, and in individuals, up to 35%.ConclusionsIn ARDS, CO2 elimination is importantly enhanced by an inspiratory flow pattern with long MDT and high EIF. An optimal inspiratory pattern allows a reduction of tidal volume and may be part of lung-protective ventilation.

Computer simulation allows goal-oriented mechanical ventilation in acute respiratory distress syndrome

IntroductionTo prevent further lung damage in patients with acute respiratory distress syndrome (ARDS), it is important to avoid overdistension and cyclic opening and closing of atelectatic alveoli. Previous studies have demonstrated protective effects of using low tidal volume (VT), moderate positive end-expiratory pressure and low airway pressure. Aspiration of dead space (ASPIDS) allows a reduction in VT by eliminating dead space in the tracheal tube and tubing. We hypothesized that, by applying goal-orientated ventilation based on iterative computer simulation, VT can be reduced at high respiratory rate and much further reduced during ASPIDS without compromising gas exchange or causing high airway pressure.MethodsARDS was induced in eight pigs by surfactant perturbation and ventilator-induced lung injury. Ventilator resetting guided by computer simulation was then performed, aiming at minimal VT, plateau pressure 30 cmH2O and isocapnia, first by only increasing respiratory rate and then by using ASPIDS as well.ResultsVT decreased from 7.2 ± 0.5 ml/kg to 6.6 ± 0.5 ml/kg as respiratory rate increased from 40 to 64 ± 6 breaths/min, and to 4.0 ± 0.4 ml/kg when ASPIDS was used at 80 ± 6 breaths/min. Measured values of arterial carbon dioxide tension were close to predicted values. Without ASPIDS, total positive end-expiratory pressure and plateau pressure were slightly higher than predicted, and with ASPIDS they were lower than predicted.ConclusionIn principle, computer simulation may be used in goal-oriented ventilation in ARDS. Further studies are needed to investigate potential benefits and limitations over extended study periods.

Multiple pressure-volume loops recorded with sinusoidal low flow in a porcine acute respiratory distress syndrome model.

Objectives:  To develop a method for automatic recording of multiple dynamic elastic pressure–volume (Pel/V) loops. To analyse the relationship between multiple dynamic Pel/V loops and static Pel/V loops in a porcine model of acute lung injury/acute respiratory distress syndrome (ALI/ARDS). To test the hypothesis that increasing lung collapse and re‐expansion with decreasing positive end expiratory pressure (PEEP) can be characterized by hysteresis of the Pel/V loops.

Measurement of Ventilation and Respiratory Mechanics during Continuous Positive Airway Pressure (CPAP) Treatment in Infants

ABSTRACT. A new method has been evaluated for measuring ventilation and lung mechanics in spontaneously breathing infants by means of a face chamber. Airway flow is measured with a pneumotachograph inserted between the face chamber and a stable pressure source. Oesophageal pressure is measured via a water‐filled oesophageal catheter. The method is suitable for use in conjunction with continuous positive airway pressure (CPAP) treatment in neonatal intensive care. A flat frequency response curve up to 15 Hz for the two measuring systems (i.e., airway flow and oesophageal pressure), and a time shift between the two respective signals of less than 2 msec are prerequisites for correct evaluation of respiratory mechanics. In preterm infants with chest distortion, the inhomogeneity of pleural pressure affects the significance of resistance and compliance values, as calculated from oesophageal pressure. Supra‐diaphragmatic pressure variations reflect the resistive and elastic load on the diaphragm exerted by the lungs and thorax. Thus, oesophageal pressure is still useful in studies of respiratory mechanics in preterm infants.

Measurement and mathematical modelling of elastic and resistive lung mechanical properties studied at sinusoidal expiratory flow

Elastic pressure/volume (Pel/V) and elastic pressure/resistance (Pel/R) diagrams reflect parenchymal and bronchial properties, respectively. The objective was to develop a method for determination and mathematical characterization of Pel/V and Pel/R relationships, simultaneously studied at sinusoidal flow–modulated vital capacity expirations in a body plethysmograph. Analysis was carried out by iterative parameter estimation based on a composite mathematical model describing a three‐segment Pel/V curve and a hyperbolic Pel/R curve. The hypothesis was tested that the sigmoid Pel/V curve is non‐symmetric. Thirty healthy subjects were studied. The hypothesis of a non‐symmetric Pel/V curve was verified. Its upper volume asymptote was nearly equal to total lung capacity (TLC), indicating lung stiffness increasing at high lung volume as the main factor limiting TLC at health. The asymptotic minimal resistance of the hyperbolic Pel/R relationship reflected lung size. A detailed description of both Pel/V and Pel/R relationships was simultaneously derived from sinusoidal flow–modulated vital capacity expirations. The nature of the Pel/V curve merits the use of a non‐symmetric Pel/V model.