Measurement of air trapping, intrinsic positive end-expiratory pressure, and dynamic hyperinflation in mechanically ventilated patients.

Severe airflow obstruction is a common cause of acute respiratory failure. Dynamic hyperinflation affects tidal ventilation, increases airways resistance, and causes intrinsic positive end-expiratory pressure (auto-PEEP). Most patients with asthma and chronic obstructive pulmonary disease have dynamic hyperinflation and auto-PEEP during mechanical ventilation, which can cause hemodynamic compromise and barotrauma. Auto-PEEP can be identified in passively breathing patients by observation of real-time ventilator flow and pressure graphics. In spontaneously breathing patients, auto-PEEP is measured by simultaneous recordings of esophageal and flow waveforms. The ventilatory pattern should be directed toward minimizing dynamic hyperinflation and auto-PEEP by using small tidal volume and preserving expiratory time. With a spontaneously breathing patient, to reduce the work of breathing and improve patient-ventilator interaction, it is crucial to set an adequate inspiratory flow, inspiratory time, trigger sensitivity, and ventilator-applied PEEP. Ventilator graphics are invaluable for monitoring and treatment decisions at the bedside.

[1]  F. Plum.  Handbook of Physiology. , 1960 .

[2]  N A Bergman,et al.  Intrapulmonary Gas Trapping during Mechanical Ventilation at Rapid Frequencies , 1972, Anesthesiology.

[3]  B Jonson,et al.  Monitoring of ventilation and lung mechanics during automatic ventilation. A new device. , 1975, Bulletin de physio-pathologie respiratoire.

[4]  P E Pepe,et al.  Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. , 1982, The American review of respiratory disease.

[5]  J. Martin,et al.  Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma. , 1982, The American review of respiratory disease.

[6]  S. Sorokin,et al.  The Respiratory System , 1983 .

[7]  C. Perret,et al.  Mechanical controlled hypoventilation in status asthmaticus. , 1984, The American review of respiratory disease.

[8]  B. Fleury,et al.  Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. , 2015, The American review of respiratory disease.

[9]  J. Marini,et al.  The inspiratory workload of patient-initiated mechanical ventilation. , 1986, The American review of respiratory disease.

[10]  D. Tuxen,et al.  The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. , 1987, The American review of respiratory disease.

[11]  J. Hall,et al.  Liberation of the patient from mechanical ventilation. , 1987, JAMA.

[12]  J. Marini,et al.  Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction , 1988 .

[13]  J. Marini,et al.  Evaluation of thoracic mechanics in the ventilated patient part II: Applied mechanics , 1988 .

[14]  T. Similowski,et al.  Acute respiratory failure of chronic obstructive pulmonary disease. , 1988, The American review of respiratory disease.

[15]  Marini Jj.  Monitoring during mechanical ventilation. , 1988, Clinics in chest medicine.

[16]  A. Rossi,et al.  Respiratory resistance and intrinsic positive end-expiratory pressure (PEEPi) in patients with the adult respiratory distress syndrome (ARDS). , 1988, The European respiratory journal.

[17]  J. Marini.  Monitoring during mechanical ventilation. , 1988, Clinics in chest medicine.

[18]  J. Marini,et al.  Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. , 1989, Journal of applied physiology.

[19]  J Moxham,et al.  Weaning From Mechanical Ventilation , 2004 .

[20]  J. Marini.  Should PEEP be used in airflow obstruction? , 1989, The American review of respiratory disease.

[21]  G. Schmidt,et al.  Acute or chronic respiratory failure. Assessment and management of patients with COPD in the emergency setting. , 1989, JAMA.

[22]  M. Tobin,et al.  PEEP, auto-PEEP, and waterfalls. , 1989, Chest.

[23]  D. Tuxen.  Detrimental effects of positive end-expiratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. , 1989, The American review of respiratory disease.

[24]  J. Milic-Emili,et al.  Intrinsic PEEP and arterial PCO2 in stable patients with chronic obstructive pulmonary disease. , 1990, The American review of respiratory disease.

[25]  M. Abel,et al.  Physiologic approach to mechanical ventilation , 1990, Critical care medicine.

[26]  J. Milic-Emili,et al.  Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. , 1990, The American review of respiratory disease.

[27]  J. Hall,et al.  Management of the critically ill asthmatic patient. , 1990, The Medical clinics of North America.

[28]  M. Pinsky,et al.  Auto-PEEP during CPR. An "occult" cause of electromechanical dissociation? , 1991, Chest.

[29]  S. Gottfried.  The Role of PEEP in the Mechanically Ventilated COPD Patient , 1991 .

[30]  V. Ranieri,et al.  A simple method for the measurement of intrinsic positive end‐expiratory pressure during controlled and assisted modes of mechanical ventilation , 1992, Critical care medicine.

[31]  C. Perret,et al.  Respiratory Failure in Asthma: Management of the Mechanically Ventilated Patient , 1992 .

[32]  V. Ninane,et al.  Intrinsic PEEP in patients with chronic obstructive pulmonary disease. Role of expiratory muscles. , 1993, The American review of respiratory disease.

[33]  Patient-ventilator interaction: rational strategies for acute ventilatory management , 1993 .

[34]  V. Ranieri,et al.  Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. , 1993, The American review of respiratory disease.

[35]  R. Fernandez,et al.  Relationship between expired capnogram and respiratory system resistance in critically ill patients during total ventilatory support. , 1994, Chest.

[36]  G. Bernard,et al.  Effect of bronchodilators on lung mechanics in the acute respiratory distress syndrome (ARDS). , 1994, Chest.

[37]  R. Fernandez,et al.  Hemodynamic responses to external counterbalancing of auto‐positive end‐expiratory pressure in mechanically ventilated patients with chronic obstructive pulmonary disease , 1994, Critical care medicine.

[38]  S. Gottfried,et al.  Comparison of static and dynamic measurements of intrinsic PEEP in anesthetized cats. , 1994, Journal of applied physiology.

[39]  D. Tuxen.  Permissive hypercapnic ventilation. , 1994, American journal of respiratory and critical care medicine.

[40]  P. Pelosi,et al.  Lung structure and function in different stages of severe adult respiratory distress syndrome. , 1994, JAMA.

[41]  P. Romero,et al.  Efecto de la PEEP sobre la mecánica pulmonar y el capnograma espiratorio en pacientes con enfermedad pulmonar obstructiva crónica ventilados mecánicamente , 1995 .

[42]  L. Brochard,et al.  Expiratory muscle activity increases intrinsic positive end-expiratory pressure independently of dynamic hyperinflation in mechanically ventilated patients. , 1995, American journal of respiratory and critical care medicine.

[43]  J. Guttmann,et al.  An analysis of desynchronization between the spontaneously breathing patient and ventilator during inspiratory pressure support. , 1995, Chest.

[44]  P. Pelosi,et al.  Alterations of lung and chest wall mechanics in patients with acute lung injury: effects of positive end-expiratory pressure. , 1995, American journal of respiratory and critical care medicine.

[45]  Jesse B. Hall,et al.  The assessment and management of adults with status asthmaticus. , 1995, American journal of respiratory and critical care medicine.

[46]  Robert M. Kacmarek,et al.  Essentials of Mechanical Ventilation , 1996 .

[47]  J. Leatherman,et al.  Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: hidden auto-positive end-expiratory pressure. , 1996, Critical care medicine.

[48]  B. Fiquet,et al.  Comparison of the effects of heat and moisture exchangers and heated humidifiers on ventilation and gas exchange during weaning trials from mechanical ventilation. , 1996, Chest.

[49]  P. Pelosi,et al.  Effects of heat and moisture exchangers on minute ventilation, ventilatory drive, and work of breathing during pressure-support ventilation in acute respiratory failure. , 1996, Critical care medicine.

[50]  C. Roussos,et al.  Respiratory muscles and weaning failure. , 1996, The European respiratory journal.

[51]  S. Epstein,et al.  Influence of gender and endotracheal tube size on preextubation breathing pattern. , 1996, American journal of respiratory and critical care medicine.

[52]  G. Iotti,et al.  Unfavorable mechanical effects of heat and moisture exchangers in ventilated patients , 1997, Intensive Care Medicine.

[53]  M J Tobin,et al.  Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. , 1997, American journal of respiratory and critical care medicine.

[54]  M J Tobin,et al.  Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. , 1997, American journal of respiratory and critical care medicine.

[55]  C. Roussos,et al.  Accurate measurement of intrinsic positive end-expiratory pressure: how to detect and correct for expiratory muscle activity. , 1997, The European respiratory journal.

[56]  J. Venegas,et al.  Effects of nebulized salbutamol on respiratory mechanics in adult respiratory distress syndrome , 1997, Intensive Care Medicine.

[57]  Arthur S Slutsky,et al.  A computed tomography scan assessment of regional lung volume in acute lung injury. The CT Scan ARDS Study Group. , 1998, American journal of respiratory and critical care medicine.

[58]  M. Tobin,et al.  Influence of ventilator settings in determining respiratory frequency during mechanical ventilation. , 1999, American journal of respiratory and critical care medicine.

[59]  Paolo Navalesi,et al.  Neural control of mechanical ventilation in respiratory failure , 1999, Nature Medicine.

[60]  M. Younes,et al.  Effect of ventilator flow rate on respiratory timing in normal humans. , 1999, American journal of respiratory and critical care medicine.

[61]  Yoshitsugu Yamada,et al.  Analysis of the mechanisms of expiratory asynchrony in pressure support ventilation: a mathematical approach. , 2000, Journal of applied physiology.

[62]  E. Kondili,et al.  How to set the ventilator in asthma. , 2000, Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace.

[63]  A. Lymberis,et al.  Intrinsic positive end-expiratory pressure in mechanically ventilated patients with and without tidal expiratory flow limitation , 2000, Critical care medicine.

[64]  M. Younes.  Dynamic Intrinsic PEEP (PEEPi,dyn) , 2000 .

[65]  L. Brochard,et al.  Airway Occlusion Pressure to Titrate Positive End-expiratory Pressure in Patients with Dynamic Hyperinflation , 2000, Anesthesiology.

[66]  M. Younes.  Dynamic intrinsic PEEP (PEEP(i),dyn): is it worth saving? , 2000, American journal of respiratory and critical care medicine.

[67]  A Lymberis,et al.  Expiratory flow limitation and intrinsic positive end-expiratory pressure at zero positive end-expiratory pressure in patients with adult respiratory distress syndrome. , 2000, American journal of respiratory and critical care medicine.

[68]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[69]  R. Branson,et al.  The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients. , 2000, Respiratory care.

[70]  M. Tobin,et al.  Patient-ventilator interaction. , 2001, American journal of respiratory and critical care medicine.

[71]  C S Sassoon,et al.  Patient-ventilator asynchrony , 2001, Current opinion in critical care.

[72]  M J Tobin,et al.  Advances in mechanical ventilation. , 2001, The New England journal of medicine.

[73]  L. Blanch,et al.  Non-invasive mechanical ventilation in status asthmaticus , 2001, Intensive Care Medicine.

[74]  L. Brochard.  Intrinsic (or auto-) positive end-expiratory pressure during spontaneous or assisted ventilation , 2002, Intensive Care Medicine.

[75]  F. Jardin,et al.  Increasing respiratory rate to improve CO2 clearance during mechanical ventilation is not a panacea in acute respiratory failure* , 2002, Critical care medicine.

[76]  L. Brochard.  Intrinsic (or auto-) PEEP during controlled mechanical ventilation , 2002, Intensive Care Medicine.

[77]  C. Roussos,et al.  Effects of positive end-expiratory pressure on gas exchange and expiratory flow limitation in adult respiratory distress syndrome* , 2002, Critical care medicine.

[78]  Arthur S Slutsky,et al.  ARDSNet lower tidal volume ventilatory strategy may generate intrinsic positive end-expiratory pressure in patients with acute respiratory distress syndrome. , 2002, American journal of respiratory and critical care medicine.

[79]  C. Roussos,et al.  Clinical review: Severe asthma , 2001, Critical care.

[80]  L. Brochard,et al.  Influence of respiratory rate on gas trapping during low volume ventilation of patients with acute lung injury , 2002, Intensive Care Medicine.

[81]  E. Kondili,et al.  Patient-ventilator interaction. , 2003, British journal of anaesthesia.

[82]  E. R. Mcfadden,et al.  Acute severe asthma. , 2003, American journal of respiratory and critical care medicine.

[83]  J. Mancebo.  Triggering and cycling off during pressure support ventilation: simplicity or sophistication? , 2003, Intensive Care Medicine.

[84]  C. Alexopoulou,et al.  Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease , 2004, Intensive Care Medicine.

[85]  R. Shapiro,et al.  Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma , 2004, Critical care medicine.

[86]  R. Fernandez,et al.  Intrinsic PEEP: a cause of inspiratory muscle ineffectivity , 2004, Intensive Care Medicine.

[87]  A. Rossi,et al.  Intrinsic positive end-expiratory pressure (PEEPi) , 1995, Intensive Care Medicine.

[88]  D. Patakas,et al.  Effects of breathing patterns on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation , 1995, Intensive Care Medicine.

[89]  R. Veronesi,et al.  Respiratory mechanics by least squares fitting in mechanically ventilated patients: Applications during paralysis and during pressure support ventilation , 1995, Intensive Care Medicine.

[90]  Wasted efforts and dyssynchrony: Is the patient-ventilator battle back? , 1995, Intensive Care Medicine.