Abstract
BACKGROUD: Lung volume measurements are important for monitoring functional aeration and recruitment and may help guide adjustments in ventilator settings. The expiratory phase of airway pressure release ventilation (APRV) may provide physiologic information about lung volume based on the expiratory flow-time slope, angle, and time to approach a no-flow state (expiratory time [TE]). We hypothesized that expiratory flow would correlate with estimated lung volume (ELV) as measured using a modified nitrogen washout/washin technique in a large-animal lung injury model.
METHODS: Eight pigs (35.2 ± 1.0 kg) were mechanically ventilated using an Engström Carescape R860 on the APRV mode. All settings were held constant except the expiratory duration, which was adjusted based on the expiratory flow curve. Abdominal pressure was increased to 15 mm Hg in normal and injured lungs to replicate a combination of pulmonary and extrapulmonary lung injury. ELV was estimated using the Carescape FRC INview tool. The expiratory flow-time slope and TE were measured from the expiratory flow profile.
RESULTS: Lung elastance increased with induced lung injury from 29.3 ± 7.3 cm H2O/L to 39.9 ± 15.1cm H2O/L, and chest wall elastance increased with increasing intra-abdominal pressures (IAPs) from 15.3 ± 4.1 cm H2O/L to 25.7 ± 10.0 cm H2O/L in the normal lung and 15.8 ± 6.0 cm H2O/L to 33.0 ± 6.2 cm H2O/L in the injured lung (P = .39). ELV decreased from 1.90 ± 0.83 L in the injured lung to 0.67 ± 0.10 L by increasing IAP to 15 mm Hg. This had a significant correlation with a TE decrease from 2.3 ± 0.8 s to 1.0 ± 0.1 s in the injured group with increasing insufflation pressures (ρ = 0.95) and with the expiratory flow-time slope, which increased from 0.29 ± 0.06 L/s2 to 0.63 ± 0.05 L/s2 (ρ = 0.78).
CONCLUSIONS: Changes in ELV over time, and the TE and flow-time slope, could be used to demonstrate evolving lung injury during APRV. Using the slope to infer changes in functional lung volume represents a unique, reproducible, real-time, bedside technique that does not interrupt ventilation and may be used for clinical interpretation.
- end-expiratory lung volume
- expiratory flow
- airway pressure release ventilation
- time-controlled adaptive ventilation
Footnotes
- Correspondence: Michaela Kollisch-Singule MD, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210. E-mail: KolliscM{at}upstate.edu
Dr Kollisch-Singule discloses a relationship with Dräger Medical Systems. Dr Habashi is the founder of ICON, of which Ms Andrews is an employee. Dr Habashi holds patents on a method of initiating, managing, and/or weaning airway pressure release ventilation, as well as controlling a ventilator in accordance with the same. Drs Kaczka and Herrmann are co-founders and shareholders of OscillaVent, and are co-inventors on a patent involving multifrequency oscillatory ventilation. Drs Kaczka and Herrmann disclose a relationship with ZOLL Medical. Dr Kaczka discloses a relationship with Lungpacer Medical. The remaining authors have disclosed no conflicts of interest. The authors maintain that industry had no role in the design and conduct of the study; the collection, management, analysis, or interpretation of the data; nor the preparation, review, or approval of the manuscript.
Portions of these data were presented at the 2022 Upstate New York American College of Surgeons Committee on Trauma Resident Paper Competition November 2, 2022, in Buffalo, New York; and at the 2023 American Thoracic Society International Conference, held May 19–24, 2023, in Washington, District of Columbia.
This study was supported by NIH R01 HL142702-04 as well as an educational research grant from Dräger Medical Systems. It was supported in part by the Office of the Assistant Secretary of Defense for Health Affairs, Peer Reviewed Medical Research Program awards W81XWH-20-1-0696 and W81XWH-20-1-0507. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense.
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