Implications of a Biphasic Two-Compartment Model of

Constant Flow Ventilation for the Clinical Setting

John R. Hotchkiss, Jr., Philip S. Crooke, Alexander B. Adams, and John J. Marini

Purpose: To investigate the theoretical effects of chang- sensitive to such changes. Compartmental ventilation
ing frequency (f), duty cycle (D), or end-inspiratory was much less uniform than compartmental peak
pause length on the distribution of ventilation and pressure. Ventilation could not be made entirely uni-
compartmental pressure in a heterogeneous, two com- form by changes of f, D, or pause within the usual
partment pulmonary model inflated by constant flow. clinical range.
Methods: Differential equations governing compart- Conclusions: In a linear, two compartment model of
mental volume changes were derived and solved. the respiratory system, disparity of compartmental
Validation was conducted in a mechanical lung ana- end-expiratory pressures is the primary mechanism by
logue with two mechanically independent compart- which changes off, D, or pause alter the distribution of
ments. Model predictions were then generated over ventilation during inflation with constant flow. Ventila-
wide ranges of 5, D, or end-inspiratory pause. tion is less evenly distributed than peak alveolar
Results: Disparity of compartmental end-expiratory pressure, and there are limits to the beneficial effects
pressure was identified as the primary mechanism by on the distribution of ventilation to be gained from
which changes in f, D, or pause alter the distribution of manipulations of machine settings.
ventilation. Distribution of peak pressures was less Copyright o 1994 by W.B. Saunders Company

HE DISEASED LUNG is both anatomi-

T cally and functionally heterogeneous, of-
ten comprised of gas exchanging units that can
be classified into distinct subtypes.19J2~32~44
Me-
chanical heterogeneity may characterize even
those conditions that appear symmetrical on a
routine frontal radiograph, such as acute lung
injury.22,23 In a heterogeneous lung, regional
pressures and ventilatory kinetics may be more
relevant to gas exchange and the risk of baro-
trauma than is the common pressure profile
applied to the airway opening.20,22T32The impor-
tance of controlling alveolar pressure has be-
come clear as the full range and prevalence of
barotrauma have been brought to attention.
There has also been increasing awareness of
the untoward effects of dynamic hyperinflation,
which can increase mean alveolar pressure,
impede central venous return, increase the
work of breathing, and limit ventilation in pres-
sure-assisted breathing.31,39 As will be shown,
From the Department of Medicine, University of Minnesota,
St Paul, Minnesota; and the Depamnent of Mathematics,
Vanderbilt University, Nashville, Tennessee.
Received November 9, 1993; accepted January 16, 1994.
Supported by grant no. MOl-RROO40, National
Research Resources, General Clinical Research
gram; SCOR grant no. 1~50 HL 501.52-01, National
Lung and Blood Institute; and The Ramsey Foundation.
Address reprint requests to John J. Marini, MD, Pulmonary
and Critical Care Medicine, St Paul Ramsey Medical
640 Jackson St, St Paul, Minnesota 55101-2595.
Copyright o 1994 by W.B. Saunders Company
0883-9441/94/0902-0005$05.00/0
regional differences in auto-positive end-expira-
tory pressure (auto-PEEP) may also influence
the partitioning of ventilation and peak pres-
sure in response to a common central airway
pressure.
Many elegant and useful mathematical mod-
els have been developed to characterize respira-
tory system behavior. 2-4,7,9,13,21,25,28,35,36,40,49 How-
ever, relatively few have simultaneously
considered parallel two-compartment systems,
addressed the frequent disparity between inspi-
ratory and expiratory resistances,“J8 and al-
lowed for the possibility of dynamic hyperinfla-
tion while focusing on the overall changes in the
distribution of ventilation and peak pressure
that result from common clinical manipulations
of ventilator settings. In the current work, we
developed a two-compartment linear model for
respiratory system behavior in response to con-
stant flow ventilation (CFV), which incorpo-
rates all of these features. Our findings empha-
size the central importance of regional
differences in auto-PEEP to the partitioning of
ventilation between compartments, an empha-
sis on the expiratory phase suggested by the
earlier work of Connors et all7
Center for
Centers Pro- MATERIALS AND METHODS
Heart,
Dejinitions and Assumptions
The system modeled has two compartments (designated 1
Center, and 2), each characterized by its own compliance, inspira-
tory resistance, and expiratory resistance. These parallel
compartments connect at a branch point to a common
airway, which itself has independent inspiratory (RIG) and

114 JournalofCrificalCare, Vol9,No 2 (JuneL1994: pp 114-123

TWO-COMPARTMENT MODEL OF CONSTANT FLOW 115

Effect of end-inspiratov (protoexpiratory) pause. During

an end-inspiratory pause, the system is closed, and gas will
flow from the higher pressure compartment to the lower
pressure compartment (pendelluft). During this pause, the
appropriate flow equations are

%(t) = ArV,(t) + BrVJt)

dVZ
dt (t) = - T(t) (4)

Here AP and Bp are constants that are functions of

compartmental resistance and compliance, which differ
from their counterparts in equation I. Equations 3 and 4
may be solved to yield expressions for compartmental
Fig 1. Schematic diagram of the modeled system. Abbrevia- volume as a function of time.
tions: R,c, Rsc = inspiratory and expiratory resistance of the
Linking the phases of the ventilatoty cycle. We used an
common airway; R,,, Rs, = inspiratory and expiratory resis-
iterative method to link the inspiratory, pause, and expira-
tances of compartment 1; RQ, Rsr = inspiratory and expiratory
tory phases of the respiratory cycle. The appropriate inspira-
resistances of compartment 2; C,, C2 = compliances of com-
partments 1 and 2; V,(t), V,(t) = instantaneous volumes of tory, pause, and expiratory equations for each phase were
compartments 1 and 2; P.(t) = instantaneous branch point sequentially and cyclically applied, starting from initial
airway pressure; VsET = set inspiratory flow. dV/dt for com- compartmental volumes above elastic equilibrium position
partment Ci = (PB(t)V,(t)/CJ/R,, where Ri = R,i if compart- (FRC) of zero. The compartmental volumes predicted at
ment is filling and Ri = Rs, if compartment is emptying. the end of each phase were used as the initial volumes for
the subsequent phase, and the process was terminated when
stable values were obtained for end-expiratory and end-
expiratoty (Rnc) resistances (Fig 1). Resistances and compli- inspiratory compartmental volumes. This approach allowed
antes are assumed constant, and compartmental interaction outcome variables to be expressed purely as functions of
ta,kes place solely at the branch point. Inspiratory flow inspiratoty resistance (RI), expiratory resistance (Rn). com-
(Vsrr) is an ideal square waveform, and expiration is pliance (C), and the clinician-controlled inputs: frequency
assumed to be passive. (f), duty cycle (D), and VW.

Model Derivation Validation of the Mathematical Model

Inspirafion und expiration. Under these assumptions, To test the validity of our model, we compared its
instantaneous compartmental inspiratoty or expiratory flow predictions to pressure measurements obtained in a two-
is determined by compartmental inspiratory or expiratory compartment mechanical analogue of the respiratory sys-
resistance and the difference between compartmental pres- tem (TTL model 1600; Michigan Instruments, Grand Rap-
sure and the pressure at the branch point (compartmental ids, MI) subjected to constant flow ventilation at a variety of
driving pressure). With these characteristics, instantaneous flow rates (14 to 88 L/min), frequencies (10 to 30 cycles/
flows in compartments one and two (dV,/dt and dVI/dt) min), and tidal volumes (0.84 to 1.06 L). Fixed orifice
can be shown to be resistors were used to simulate the central airway and
compartmental resistances. Compartmental compliance val-
dV1 ues were set by adjusting tensions within the spring-loaded
dt (t) = AV,(t) + BV,(t) + K,
bellows chambers. No extrinsic PEEP was applied. Using
dVz lumped, measured values for resistance and compliance as
dt (t) = GV,(t) + HVz(t) + Kz inputs to the model, predicted and measured end-inspira-
tory and end-expiratory pressures were compared for (1)
where A, B, G, and H are constants determined by compart- inspiration alone; (2) expiration alone: and (3) the total
mental resistance and compliance, which differ for inspira- respiratory cycle (Fig 2). Good correlations were observed
tion, expiration without pendelluft, and expiration with in each, indicating that the model faithfully reproduces the
pendelluft. Under constant flow conditions, it can be shown behavior of a linear. two-compartment system.
mathematically that pendelluft will not occur during passive
inspiration. K1 and Kz are functions of Vsnr and resistance Predictions of the Model for Selected
during inspiration; during expiration they are functions of
applied PEEP and resistance. The rate of volume change of
Clinical Conditions
either compartment is directly affected by the volume of its We present predictions of model behavior over ranges of
companion compartment. An increase in companion com- f, D, and pause for two configurations, each composed of a
partment volume will increase compartmental inspiratoiy “normal” compartment and a “pathological” compartment
flow and decrease compartmental expiratory flow by elevat- that displays obstructive or restrictive characteristics. Resis-
ing branch point pressure. Equations 1 and 2 may be solved tances are expressed as cm HzO/L/s and compliances as
to yield compartmental volumes as functions of time. L/cm HlO. In these simulations, Rtc = 5. Rr(, = 5, and the
116 HOTCHKISS ET AL

z 25-
2
3 20 -
L .
E 15-
z
=I IO-

1 5-

0
1. I * I * I- 1-t * I, I I I , , 7, I 8, I I, I

0 5 10 15 20 25 30 35 40 0 5 10 15 20 25 30 35 40
A B
Predicted Pressure (cmH,O) Predicted Pressure kmH,Ol

Fig 2. Scatter plots of predicted v measured end-inspiratory and end-expiretory compartmental pressures obtained in validation
experiments. (A) The inspiratory (A) and expiratory (m) phases are considered in isolation. (6) The total respiratory cycle is
considered. For inspiration alone: Ppred = 0.96 Pmeas + 0.74; n = 48, r = .99. For expiration alone: Ppred = 1.01 Pmeas + 0.74;
n = 72, r = .98. For inspiration and expiration combined: Ppred = 1.08 Pmeas + 0.82; n = 96.r = .86.

normal compartment (always designated as compartment
one) was assigned Rrr = 2, Rar = 3, and Cr = 0.05. The
obstructed compartment was given the values Rr2 = 15,
Rm = 35, and Cz = ,035, whereas the restricted compart-
ment was assigned Rrz = 3, Rm = 5, and Cz = ,015. To
elucidate the interaction between the inspiratory and expira-
tory phases of CFV in distributing flow and pressure, we
investigated both the isolated inspiratory phase and bipha-
sic ventilation for each configuration. In isolated inspira-
tion, either flow rate and the absolute difference in auto-
PEEP between compartments (A AP) were specified, or A
AP was set at zero and flow rate was varied. Two outcome
variables were examined: (1) the compartmental tidal vol-
ume ratio (Vra), defined as the quotient of the tidal volume
of compartment 1 (the normal compartment) by the tidal
volume of compartment 2 (the abnormal compartment);
and (2) the peak alveolar pressure ratio (Pra), defined as
the quotient of the end-inspiratory (peak) pressure in
compartment 1 (normal) by the end-inspiratory pressure in
compartment 2 (abnormal). Vra tracks the distribution of
ventilation, with a value of unity representing uniform
ventilation and values higher or lower than unity indicating
nonuniform ventilation. Pra tracks the distribution of peak
alveolar pressure; again, values deviating from unity indi-
cate nonuniformity.
RESULTS
Predictions for Isolated Inspiration
In isolated inspiration, Vra was strikingly
affected by clinically relevant levels of A AP,
with increasing levels of auto-PEEP in the long
expiratory time constant compartment widen-
ing the disparity of ventilatory distribution in
the obstructive setting and narrowing it in the
restrictive setting (Fig 3). The effects of isolated
changes in flow rate were much smaller. PpRwas
little affected by either flow rate or A AP; the
only significant effect for either variable oc-
curred for PpRversus flow rate in the obstructive
setting in which increasing flow rates increased
the PpR (A AP = 0).
Predictions for Total Ventilatory Cycle
Obstruction. The duty-cycle (flow) and fre-
quency-dependent behaviors of the biphasic
obstructive configuration (incorporating the ex-
piratory phase) are shown in Fig 4. The most
notable features are the existence, within the
clinical range, of an optimal duty-cycle for
minimizing Vra and a frequency associated with
a peak in Pra. The value of D associated with
the VrR minimum depends on the disparity
between RI2 and R,,; as the ratio R,JR,, ap-
proaches unity, the nadir moves to lower values
of D. Vr, then increases monotonically as D is
increased. In contrast, as RI2 approaches RI,,
the PpR peak moves to higher frequencies (data
not shown). Also, the general behavior and
shape of the curves obtained by increasing fre-
quency (and V,), at a fixed VT or by increasing
frequency with VE held constant are identical;
however, absolute values for pressure and venti-
lation are higher in the former case (data not
shown). Finally, in this linear model, peak
compartmental pressure is higher in the normal
compartment, which also receives a greater
fraction of Vr.
TWO-COMPARTMENT MODEL OF CONSTANT FLOW 117

Fig 3. Model predictions for ;

effects of compartmental auto- t
PEEP disparity (A AP, upper pan-
els) and flow rate (V,.,, lower o
panels) on VTR and Prs ratios dur- 0 1 a 12 (6
ing isolated inspiration. Vrs = A Auto-PEEP lcmH,Ol
Ratio of tidal volume of normal
to abnormal compartment. Pps = 3.5
Ratio of peak pressure of normal
to abnormal compartment. In the 3.0
upper two panels, VT = 1.28 I, -E
V,, = 0.853 lsec-‘, and A AP is z 2.5
imposed by arbitrarily increasing .E
the auto-PEEP of the obstructed = 1.0
compartment in the obstructive 5
configuration or of the normal ‘.r
compartment in the restrictive
configuration. In the lower two ‘J
panels, VT = 1.28 L, and there is
no auto-PEEP disparity.

Restriction. The duty cycle and frequency-
dependent behaviors of the restrictive biphasic
configuration are converse to those of its obstruc-
tive counterpart (Fig 5). In this case, there is a
local maximum for VrR within the usual clinical
range of duty cycle. This reflects the increasing
influence of A AP (increasing auto-PEEP in the
normal compartment) as the duty cycle extends.
Variations in the Ri2/Rn ratio have relatively
little effect on the location of this peak, due
largely to the low values chosen for these
resistances (data not shown). As in the obstruc-
tive simulation, curve form was unchanged
whether V-r was held cpnstant as frequency was
increased (increasing V,) or decreased to main-
tain VE constant. In this model, fractional venti-
lation is greater in the normal compartment,
whereas peak pressures are higher in the abnor-

Fig 4. Model predictions in

the obstructive configuration.
Both phases of the respiratory
cycle interact. In the upper two
panels, VT = 1.28 L, 1= 20/min,
and pause = 0.1 (10%) or 0.2
(20%) of total cycle time. In the
lower two panels, VT = 1.28 L,
D = 0.2, 0.4, or 0.8, and pause =
0.1 or 0.2 of total cycle time.
118
Frqqwney Imln-‘I
ma1 compartment, again, unlike the obstructive
case.
DISCUSSION
Disparity in the values of compartmental
end-expiratory pressure (auto-PEEP) results in
differences in compartmental driving pressures
and emerges as the major mechanism by which
changes in f, D, or pause alter the distribution
of ventilation in a given configuration. The
direct effect of the inspiratory flow rate (inde-
pendent of its effect on A AP) is much less
significant. Notably, VrR is more sensitive to
either A AP or flow rate than is PPR.The effect
of an auto-PEEP disparity is similar in both
restrictive and obstructive conditions, in that a
widening A AP increases the relative ventilation
of the compartment with the shorter expiratory
time constant. However, the clinical implica-
tions of an increasing A AP are quite different
for the two impedance configurations; increas-
ing A AP increases the relative ventilation of the
abnormal compartment in the restrictive set-
ting, whereas it further decreases the relative
ventilation of the abnormal compartment in the
obstructive setting.
The effects of common clinical manipulations
of f, D, or pause on VrR are those expected
from their effects on expiratory time and, hence,
on compartmental auto-PEEP. The behavior of
PpR in response to these changes is more com-
HOTCHKISS ET AL
Fig 5. Model predictions in
the restrictive configuration. Both
phases of the respiratory cycle
interact. In the upper panels,
VT = 1.28 L, f= 20/min, and
pause = 0.1 or 0.2 of total cycle
time. In the lower two panels,
VT = 1.28 L, D = 0.2, 0.5, or 0.8,
and pause = 0.1 or 0.2 of total
Fraquwocy (mid’1 cycle time.
plex, because the effect of A AP on PpR is not
nearly as dominant as it is for VTR. In both
restrictive and obstructive conditions, there is a
much greater disparity in compartmental venti-
lation than in compartmental pressure, with the
normal compartment receiving the greater frac-
tion of total ventilation. This disparity of ventila-
tion cannot be entirely eliminated by manipula-
tions off, D, or pause, suggesting a limit to the
potential benefits obtainable by such ventilator
changes within the usual clinical range.
The current model differs from its predeces-
sors in important ways. Numerous previous
models have focused on inspiratory1-3,“,8,14,16,24,4’
or expiratoxy5J5 events in isolation. Those that
have explicitly considered a biphasic respiratory
cycle have generally assumed sinusoidal inputs
with equal inspiratory and expiratory compart-
mental resistances.10~25~37 These approaches have
proved fruitful in analyzing the frequency-
dependence of respiratory system compliance,
as well as in determining the inspiratory distribu-
tion of flow in the absence of regional air
trapping. However, the possibility of dynamic
hyperinflation has largely been ignored in such
analyses. By considering the interaction of inspi-
ratory and expiratory phase events, not assum-
ing equal inspiratory and expiratory resistances,
and modeling constant flow ventilation, the
current model describes the distributions of
tidal volume and peak pressure as functions of
TWO-COMPARTMENT MODEL OF CONSTANT FLOW
clinician-controlled variables. It also identifies
disparity of compartmental end-expiratory pres-
sures as the primary determinant of ventilator-y
distribution.
Because the current model does not assume
elastic equilibrium before inspiration, its inspi-
ratory equations differ somewhat from those of
the model effectively used in vivo by oth-
ers.1.7~rhJ8,4rNonetheless, our predictions for
isolated inspiration are comparable when simi-
lar values of resistance and compliance are used
in the isolated inspiratory equations (in both,
higher inspiratory flow rates increase the rela-
tive filling of the shorter time constant compart-
ment). Predictive differences between the bipha-
sic distributions of ventilation considered by
this model and those of the isolated inspiratory
model of Bake et al,’ Connolly et al,lh and
Pedley et al”s arise predominantly from the
effects of A AP on the distribution of inspiratory
flow. Finally, the current model differs from
that of Barbini,4 in that it is described by a
unified and well-characterized system of linear
differential equations and considers much wider
input ranges. Although both models predict
similar behavior over low frequencies and short
duty cycles, Barbini confined his attention to an
f of 10 cycles/min and a duty cycle range of 0.25
to 0.40.4 Consequently, the importance of re-
gional auto-PEEP effects was not illustrated in
that work.
Critique and Limitations of the Current Model
In the interpretation of our predictions, it
must be borne in mind that we make no assump-
tions regarding the relative capacities of the two
compartments being compared. Therefore, val-
ues for resistance and compliance may reflect
differences in compartmental size as well as
intrinsic impedance. Consequently, if compart-
mental compliance were reduced because of
smaller capacity (rather than by an increase of
tissue elastance), receiving less ventilation might
be physiologically appropriate.
Perhaps the most serious criticism of this
model is that it has not been validated in vivo.
Our validation in the mechanical analogue indi-
cates that the model accurately predicts the
behavior of a linear system composed of two
isolated compartments; in contrast, the dis-
eased lung may be composed of many interde-
119
pendent compartments, any of which may de-
part from linear behavior. The rigorous
quantification of such nonlinearities would re-
quire either invasive measurement of pressure
in multiple alveolar compartments or the use of
a complex nonlinear model and empirically
estimated system parameters before prediction
of system behavior. Both approaches may be
problematic in the clinical setting. Accordingly,
to approach the question of clinical relevance of
the linear model, we addressed the qualitative
effects of several physiologically plausible depar-
tures from purely linear, independent, two-
compartment behavior on the predictions of
this model. We reasoned that if the inclusion of
such effects does not alter the qualitative predic-
tions of the model, their presence in the clinical
setting should not severely compromise the
validity of our qualitative conclusions.
Extension to multiple compartments. The
independent two-compartment configuration we
modeled is undoubtedly a gross oversimplifica-
tion of the multiple interactive compartments of
the diseased lung. However, the expiratory data
of Bates et al5 and Chelucci et alI5 and the
inspiratory data of Bake et al’ and Connolly et
all6 suggest that such a representation may still
have clinical relevance. Furthermore, the ef-
fects of branch point pressure on expiratory
flow and of auto-PEEP on inspiratory flow are
similar in any parallel array. Even ignoring
other types of compartmental interaction, a
larger number of parallel compartments theo-
retically leads to greater interaction through the
branch point during expiration, with subsequent
reduction of A AP, a finding recently noted
empirically in a four-compartment mechanical
model by Kirmse et a1.l’ In a sense, then, a
two-compartment system highlights the com-
mon principles of multicompartmental mechan-
ics; the extent to which these principles remain
of major significance as the number of compart-
ments is increased remains uncertain.
Parenchymal interaction. The assumption
that compartments interact only through the
branch point is also open to question, especially
in conditions in which similar pathology is
widely distributed, eg, diffuse pulmonary edema
or asthma. Parenchymal interaction between a
given compartment and neighboring compart-
ments could either decrease or increase the
120 HOTCHKISS ET AL

effective compliance of the compartment under
consideration. The strength and nature of such
interactions may vary widely and unpredictably
between patients, because they depend on indi-
vidual geometry and tissue characteristics.
In other unpublished work, we have investi-
gated the theoretical effects of such interactions
using a mathematical model in which compart-
mental elastance is a function of companion
compartment volume. Figure 6 illustrates predic-
tions obtained in the obstructed configuration
when compartmental elastance is assumed to be
an increasing or decreasing linear function of
the absolute or fractional volume of the compan-
ion compartment. The qualitative features of
the V,, curve observed in the independent,
two-compartment, linear model were well pre-
served. The form of the PpR curve was also
relatively well maintained, except at very high
levels of compartmental interaction (effect of
companion compartment volume five times that
of intrinsic elastance), where it was shifted
downward and flattened. Numerous other types
and degrees of nonlinear interaction yielded
similar data when tested in both obstructive and
restrictive configurations. Therefore, tractive or
compressive parenchymal interaction does not
appear to invalidate the qualitative predictions
of the linear model.
Viscoelastic and viscoplastic behavior. The
independent two-compartment model also does
not address viscoelastic or viscoplastic behavior,
topics that have been explored by others.6J9a45-47
Viscoelastance implies stress relaxation and
time-dependent compliance, complicating sys-
tem behavior, especially in the setting of resis-
tive heterogeneity. An adequate treatment of
this intriguing problem is beyond the scope of
this paper.
Nonlinear resistances and compliances. Fur-
ther concern may arise regarding the assump-
tion of constant values for resistance and compli-
ance over a range of tidal volumes and flows.
For certain global outcomes, such as tidal vol-
ume and average peak and end-expiratory alveo-
lar pressures, “lumped” impedance parameters
yield quite acceptable predictions, even in clearly
nonlinear systems. l2 Furthermore, the work of
Bake, Rossi, Shardonofsky, and their respective
colleagues suggests that constancy of imped-
ance parameters characterizing the overall sys-
tem behavior may often be a reasonable initial
assumption in the clinical setting, especially
during constant inspiratory flow.‘,41343Our initial
investigations of a two-compartment model in-
corporating volume and flow dependent resis-
tances, as well as volume dependent elastances,
suggest that the qualitative forms of the PpR and

Fig 6. Nonlinear model pre-

dictions in the presence of paren-
chymal interaction between com-
partments. Abbreviations: &, =
compartmental elastance when
companion compartment volume
(above FRC) is 0; V,,= compart-
mental volume above FRC; Vs =
companion compartment volume
above FRC; y = arbitrary con-
stant. Compartmental values for
E,, and resistance are the same as
used in the obstructive configura-
tion of the linear model. Curve 2
represents tractive compartmen-
tal interaction (etastance de-
creases as companion compett-
ment volume increases). Curves
3 to 5 represent compressive
compartmental interaction (elas-
tance increases as companion
compartment volume increases).
TWO-COMPARTMENT MODEL OF CONSTANT
VrK curves are preserved. The results obtained
with simple forms of such functional depen-
dence (linear variation of elastance with volume
and variation of resistance either with V4’” or
exponentially with flow) are depicted for the
obstructive configuration in Fig 7 (to emphasize
volume dependence of resistance, we tested
V”!-’ so as to reflect only the change in radius
expected for a cylinder embedded in a sphere,
ignoring the counterbalancing effect of cylinder
elongation or shortening). The illustration rep-
resents the maximal theoretical effect in this
geometry. Similar preservation of curve form
was seen in the restrictive setting, as well as with
different functional forms of impedance nonlin-
earity and higher degrees of dependence on
volume and flow. As the exact functional forms
and the magnitude of the effects will vary from
patient to patient and are quite difficult to
assess in the routine clinical setting, we feel that
the purely linear model offers the advantage of
simplicity while still adequately predicting the
qualitative effects of changes in f, D, or pause.
Finally, there may be some reservation regard-
ing the specific values chosen for the system’s
resistances and compliances. The values we
assumed for total respiratory system compli-
ance and resistance are well within the clinical
range.- 34 When compartmental resistances and
Fig 7. Nonlinear model pre-
dictions for volume or flow de-
pendent resistances and volume
dependent elastances. Abbrevia-
tions: V = compartmental vol-
ume above FRC; dV/dt = abso-
lute value of compartmental
flow; RI, = resistance at flow of
1.0 L/s (curve 3) or resistance at
FRC (curve 4); E. = elastance at
FRC. Compartmental values for
R. and Es are the same as used in
the obstructive configuration of
the linear model.
FLOW 121
compliances were varied over two orders-of-
magnitude (preserving their relative values) or
REC was varied from 5 to 20 cm H20/L/s, the
shapes of the Vra and Ppa curves were largely
preserved, although the locations and values of
maxima and minima were somewhat shifted.
These findings suggest that the underlying prin-
ciples of auto-PEEP disparity and branch-point
interaction are quite robust, affecting the distri-
bution of pressure and ventilation over a wide
range of conditions.
Clinical Implications
In unilateral pneumonitis, pulmonary contu-
sion, or single lung transplantation for restric-
tive lung disease, the pulmonary system is com-
prised of a low-compliance restricted lung and a
relatively normal lung. Accordingly, maneuvers
that shorten expiratory time would theoretically
be expected to increase the ventilation and
mean alveolar pressure of the diseased lung, at
the expense of increased effective deadspace in
the normal compartment. This may or may not
improve shunt, depending on the extent to
which perfusion of the more compliant normal
lung decreases as a consequence of increasing
auto-PEEP and mean alveolar pressure.
In single-lung transplantation for obstructive
lung disease or with an obstructing lesion of a
122
mainstem bronchus, the pulmonary system has
an obstructed compartment in parallel with a
relatively normal compartment. Our model pre-
dicts that extending the duty cycle or adding an
end-inspiratory pause would decrease the venti-
lation to the obstructed lung. Such an associa-
tion between shortened expiratory time and
increased graft ventilation is consistent with
several reports in the literature.23,26~30~48 If in-
creased ventilation of the native (or obstructed)
lung is desired in the immediate postoperative
setting, short-duty cycles and no pause would be
prudent.
To the extent that the pulmonary system in
acute lung injury, chronic airflow obstruction, or
acute asthmatic crisis may be treated as a
composite of two compartments (diseased and
relatively normal subunits), the implications of
the model may apply to these conditions as well.
In the case of acute lung injury, the use of
extended duty cycles or an end-inspiratory pause
may increase the relative ventilation and auto-
PEEP of the diseased compartments, poten-
tially improving shunt and recruiting alveoli
(although at the cost of increased effective dead
space in the normal compartment). In chronic
airflow obstruction or acute asthmatic crisis, the
use of short-duty cycles and high-inspiratory
flows would theoretically improve the distribu-
tion of ventilation, as has been observed clini-
cally.” However, these manipulations may be
associated with marked elevations in peak air-
way pressure, a consequence not addressed in
this discussion.
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We have developed a biphasic linear model of
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