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Automatic monitoring of plateau and driving pressure during pressure and volume controlled ventilation
Intensive Care Medicine Experimental volume 3, Article number: A998 (2015)
Plateau pressure (Pplat) limitation is routinely used to avoid ventilator-induced lung injury. Recently, driving pressure (ΔP) was strongly associated with survival in ARDS patients .
To evaluate the feasibility of ΔP and Pplat continuous monitoring during volume (VCV) and pressure (PCV) controlled ventilation, we compared with gold standard (occlusion maneuvers at end-inspiration and end-expiration) two different methods: 1- Least Square Fitting (LSF) method that provide maneuver-free Pplat and ΔP values; 2- Mini Occlusion (MO) method by performing brief occlusion maneuvers.
We enrolled 22 patients admitted to our ICU after scheduled major abdominal surgery, with normal or restrictive respiratory system mechanics under pressure (12 pts) and volume (10 pts) controlled mechanical ventilation (G5, Hamilton Medical). We studied 12 different conditions in each patient by changing respiratory rate (10-15-20-25 bpm) and I:E ratio (1:2, 1:1, 2:1). Inspiratory pressure in PCV and tidal volume (TV) in VCV were adjusted to keep end-tidal CO2 between 32 and 36 mmHg. PEEP and FiO2 were set to maintain SpO2 ≥ 95%. ΔP, Pplat and PEEPtot reference values (ΔPREF, PplatREF and PEEPtotREF) for each ventilatory setting were obtained by 5s-length occlusion maneuvers at end-inspiration and end-expiration (ΔPREF = PplatREF - PEEPtotREF). ΔPMO values were calculated as: PplatMO - PEEPtotMO, PplatMO and PEEPtotMO being average airway pressure in the last 100 ms of mini-occlusion maneuvers lasting 400 ms. LSF applied over the whole respiratory cycle provided PplatLSF and CrsLSF values, being Crs the compliance of the respiratory system. ΔPLSF was calculated as TV/CrsLSF.
Difference with reference values was greater for MO vs. LSF, both for ΔP (0.82 ± 0.41 vs. 0.46 ± 0.82 cmH2O, respectively; p < 0.001) and Pplat (0.52 ± 0.33 vs. 0.02 ± 0.49 cmH2O; p < 0.001).
Both methods provided a good estimation of ΔP and Pplat; MO showed a slightly better precision than LSF, but a greater bias, being these differences not clinically relevant. Anyway, LSF is a totally continuous and non invasive method, whereas MO method minimally interferes with mechanical ventilation and its implementation on ICU ventilators could be more troublesome.
Amato Marcelo, et al: Driving pressure and survival in the acute respiratory distress syndrome. N Eng J Med. 2015, 372: 747-55. 10.1056/NEJMsa1410639.
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Mojoli, F., Pozzi, M., Bianzina, S. et al. Automatic monitoring of plateau and driving pressure during pressure and volume controlled ventilation. ICMx 3, A998 (2015). https://doi.org/10.1186/2197-425X-3-S1-A998
- Little Square Fitting
- Control Ventilation
- Inspiratory Pressure
- Ventilatory Setting
- Major Abdominal Surgery