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A. Respiratory Mechanics PDF
A. Respiratory Mechanics PDF
A. Respiratory Mechanics PDF
Review
Clinical review: Respiratory mechanics in spontaneous and
assisted ventilation
Daniel C Grinnan1 and Jonathon Dean Truwit2
1Fellow, Department of Pulmonary and Critical Care, University of Virginia Health System, Virginia, USA
2E Cato Drash Professor of Medicine, Senior Associate Dean for Clinical Affairs, Chief, Department of Pulmonary and Critical Care, University of
Virginia Health System, Virginia, USA
Published online: 18 April 2005 Critical Care 2005, 9:472-484 (DOI 10.1186/cc3516)
This article is online at http://ccforum.com/content/9/5/472
© 2005 BioMed Central Ltd
ARDS = acute respiratory distress syndrome; ATC = automatic tube compensation; Ccw - chest wall compliance; Cl = lung compliance; COPD =
chronic obstructive pulmonary disease; CPAP = continuous positive airway pressure; Crs = respiratory system compliance; IPL = inspiratory pres-
sure level; LIP = lower inflection point; MIP = maximal inspiratory pressure; NIPPV = noninvasive positive pressure ventilation; Pavg = average inspira-
tory pressure; Paw = airway pressure; PEEP = positive end expiratory pressure; PEFR = peak expiratory flow rate; Pes = esophageal pressure; Pex =
end-expiratory pressure; Ps = inspiratory pressure; PTI = pressure time index; PTP = pressure time product; PV = pressure–volume curve; RSBI =
472 rapid shallow breathing index; SBT = spontaneous breathing trial; UIP = upper inflection point; Vt = tidal volume; WOB = work of breathing.
Available online http://ccforum.com/content/9/5/472
Figure 1 Figure 2
Pressure–volume curve. Shown is a pressure–volume curve developed from Compliance of the lungs, chest wall, and the combined lung–chest
measurements in isolated lung during inflation (inspiration) and deflation wall system. At the functional residual capacity, the forces of
(expiration). The slope of each curve is the compliance. The difference in the expansion and collapse are in equilibrium. Reprinted from [3] with
curves is hysteresis. Reprinted from [3] with permission from Elsevier. permission from Elsevier.
Table 1
Causes of decreased measured chest wall compliance Causes of decreased measured lung compliance
Shown are the causes of decreased intrathoracic compliance, partitioned into causes of decreased measured chest wall compliance and causes of
decreased measured lung compliance.
Reduced compliance can be caused by a stiff chest wall or Respiratory system compliance is routinely recorded at the
lungs, or both. The distinction can be clinically significant. To bedside of critically ill patients. In mechanically ventilated
separate the contribution made by each to total lung patients, this is done by measuring end-expiratory alveolar
compliance, a measure of intrapleural pressure is needed. pressure (Pex) and end-inspiratory alveolar pressure (also
The most accurate surrogate marker for intrapleural pressure called peak static or plateau pressure [Ps]), so that the
is esophageal pressure, which can be measured by placing change in volume is the tidal volume (Vt). Alveolar pressure
an esophageal balloon [1]. However, this is rarely done in can easily be assessed after occlusion of the airway, because
clinical practice. Alternatively, changes in central venous the pressure in the airway equilibrates with alveolar pressure.
pressure can approximate changes in esophageal pressure, Pex is the pressure associated with alveolar distention at the
but this technique is yet to be verified [1]. end of a breath. In normal individuals this is usually zero when 473
Critical Care October 2005 Vol 9 No 5 Grinnan and Truwit
Figure 3
Compliance in emphysema and fibrosis. Shown are changes in the compliance of the inspiratory limb of the pressure–volume curve with respect to
(a) chest wall, (b) lungs, and (c) combined lung-chest wall system in patients with emphysema and fibrosis. The functional residual capacity (FRC),
represented on the vertical axis at a transmural pressure of 0, is elevated in emphysema, which can lead to dynamic hyperinflation. Reprinted from
[3] with permission from Elsevier.
referenced to atmosphere. However, when positive end- ventilator to determine whether the hypotension resolves
expiratory pressure (PEEP) is applied, Pex is at least as great when delivered breaths are withheld (Fig. 4).
as PEEP. It may be greater if air trapping occurs, and the
associated pressure beyond PEEP is termed auto-PEEP or Auto-PEEP can be measured in patients on mechanical
intrinsic PEEP. The clinician will need to know Ps, Pex, auto- ventilators by creating an end-expiratory pause. The end-
PEEP, and Vt to determine respiratory compliance at the expiratory pause maneuver allows the pressure transducer of
bedside. For example, if the PEEP is 5 cmH2O, auto-PEEP is the ventilator to approximate the end-expiratory alveolar
0 cmH2O, Ps is 25 cmH2O, and Vt is 0.5 l, then Crs = ∆V/∆P pressure, or auto-PEEP. Some ventilators allow the clinician
= 0.5 l/(25 – 5) = 0.5/20 = 0.025 l/cmH2O or 25 ml/cmH2O. to create and control the expiratory pause, whereas other
In a normal subject on mechanical ventilation, compliance ventilators perform an end-expiratory pause as an automated
should be greater than 50–100 ml/cmH2O [4]. function that requires only the push of a button. Measure-
ments of auto-PEEP require a passive patient because
Patients with obstructive lung disease have a prolonged patient interaction in breathing will alter the measurements of
expiratory phase. At baseline, most patients with emphysema the pressure transducer. In the intensive care unit, this usually
have increased compliance (because of decreased elastance requires sedation and, occasionally, paralysis.
of the lungs). If the Vt is not completely exhaled, then a
certain amount of air will be ‘trapped’ in the alveoli. If this Decreasing the amount of auto-PEEP on mechanical
continues over several breaths, then it will result in ‘stacking’ ventilation requires one to decrease the respiratory rate and
of breaths until a new end-expiratory thoracic volume is prolong the expiratory phase of ventilation. Execution of these
achieved. As the volume increases (dynamic hyperinflation), goals often requires eliminating patient effort through heavy
the functional residual capacity will be increased. As a result, sedation or paralysis. Once patient effort is eliminated, it is
tidal breathing will occur at a less compliant portion of the PV important to follow respiratory mechanics closely, including
curve (Fig. 3). auto-PEEP and compliance. In order to protect the lungs from
barotrauma, it is common to permit a certain amount of
The pressure difference associated with the trapped volume hypoventilation, termed permissive hypercapnia. Permissive
is called auto-PEEP. Caution must be used in a patient who hypercapnia has been proven safe and allows a clinician to
has obstructive lung disease and is on mechanical ventilation. use the lowest respiratory rate and Vt possible, thus
Usually, such patients are treated aggressively for airway protecting the lungs while they are impaired.
inflammation (bronchodilator treatments and corticosteroids),
while the respiratory rate is decreased and the expiratory Patients with auto-PEEP (or intrinsic PEEP) who require
phase of respiration is prolonged. If the functional residual mechanical ventilation are often asynchronous with the
capacity is increased, delivering the same Vt may increase ventilator. During assisted modes of ventilation, patients with
the transalveolar pressure, which can impede venous return auto-PEEP often have difficulty triggering the ventilator to
(resulting in hypotension) or lead to a pneumothorax. The initiate a breath. The patient must first overcome the auto-
development of hypotension in a patient with dynamic PEEP before creating the negative intrapleural pressure
hyperinflation should prompt the clinician to listen to the required to trigger the ventilator. The patient can be assisted
lungs and assess the ventilator for auto-PEEP. If auto-PEEP is by applying extrinsic PEEP, of a magnitude less than Pex, to
474 suspected, then the patient should be disconnected from the the circuit. Now the pressure needed to be generated by the
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controlled trial, low Vts (yielding plateau pressures In airways governed by laminar flow, resistance is related to
< 30 cmH2O) were compared with higher Vts (plateau the radius (r), airway length (l), and gas viscosity (η) through
pressures up to 50 cmH2O). The results showed a significant Poiseuille’s Law (R = 8ηl/πr4). This equation highlights the
decrease in mortality (from 37% to 31%) when the lung strong relation of the radius on resistance (i.e. doubling the
protective strategy (low Vt of 6 ml/kg predicted body weight) radius decreases the resistance 16-fold). When flow is
was used. That study did not use PEEP as part of the turbulent (in large airways), the equation for flow must also
ventilator strategy for lung protection. However, the incorporate a frictional factor (f). The modification of
assumption is that, by limiting Vt, fewer patients will reach a Poiseuille’s equation for turbulent flow is as follows: R =
plateau pressure greater than the UIP. Therefore, alveolar Vflη/π2r5 [25].
overdistension and excessive stretch will be minimized.
Intuitively, one might assume that the largest benefit would be At each division of the airways, the branches of the lungs lie
in the subset of patients with the poorest compliance. in parallel. With resistances in parallel, the total resistance
However, the mortality difference was independent of (Rt) is less than the individual resistances (1/Rt = 1/R1 +
respiratory system compliance, leading the investigators to 1/R2 + 1/R3 + …). Because of their large number and parallel
attribute the benefit to other factors (such as stretch). arrangement, the bronchioles are not the primary site of
However, it is not clear that the UIP can be used to set plateau greatest resistance. In a spontaneous breathing, normal
pressure and therefore avoid harmful alveolar stretch. It has person, the medium-sized bronchi are the site of greatest
been shown that alterations in alveolar recruitment will change resistance [3]. The flow–volume loop demonstrates airflow at
the UIP [14,22]. This supports the idea that the UIP represents different points in the respiratory cycle. A normal flow–volume
a decrease in alveolar recruitment. Therefore, the UIP would loop is shown in Fig. 6.
not be expected to predict reliably an alveolar phenomena
unrelated to recruitment (such as stretch or overdistension). In a normal individual maximal inspiratory flow is limited only
by muscle strength and total lung and chest wall compliance.
At present, we do not recommend routine use of the inspiratory Resistance to flow is minimal and does not limit inspiration.
PV curve in patients with ARDS. Measurements can be time Maximal expiratory flow is initially limited only by expiratory
consuming and, as evident from the above discussion, muscle strength (when the airway radius is large and
meaningful interpretation is difficult. Instead of setting PEEP resistance is minimal). However, as the airway lumen
values just above the LIP, we currently recommend following decreases, resistance to flow will increase and flow is limited
the nomogram used by the ARDS Network [21]. Recently, by resistance. The accurate measurement of airway
more attention has been given to the expiratory limb of the PV resistance during spontaneous breathing requires placement
curve. As mentioned above, PEEP is an expiratory of an esophageal balloon to estimate pleural pressure [1].
measurement, and the appropriate setting of PEEP may be This allows for the determination of the pressure gradient
estimated by a point on the expiratory curve. Holzapfel and (transpulmonary pressure equals pleural minus airway
coworkers [23] recently showed that, when manipulating PEEP pressure) at any given lung volume. Through extrapolating
according to the inflection point on the deflation limb of the PV flows at the same volume from a flow–volume loop, an
curve, intrapulmonary shunting was maximally reduced (when isovolume flow–pressure curve can be established (Fig. 7).
compared with the LIP). Although further studies are needed to By manipulating the pressure gradient at different lung
define the role of the expiratory curve in ARDS, the rationale volumes (through increasing pleural pressure), it has been
and small clinical trials appear promising. shown that maximal flow is limited once a volume-specific
pleural pressure is achieved. Several physiologic theories
Flow and resistance have been put forward in an attempt to explain this expiratory
Flow (Q) is the movement of air. Flow is dependent on a flow limitation [26].
pressure gradient (∆P) and is inversely related to the resistance
to flow (R). This relationship is described in the following The wave speed theory of flow limitation is derived from fluid
equation: Q = ∆P/R. In the lungs, two types of flow are present mechanics. When airflow approaches the speed of wave
– laminar flow and turbulent flow. In general, turbulent flow is propagation within the airway wall, flow will be limited.
present in large airways and major bifurcations, whereas According to this model, the cross-sectional area of the
laminar flow is present in the more distant airways. The type of airway, the compliance of the airway, and the resistance
flow present in an airway is influenced by the rate of flow (V), upstream from the flow limiting segment all contribute to flow
the airway radius (r), the density of gas (p), and the viscosity of limitation. This theory has been well validated during
gas (η). Reynold’s number is a calculation of the above expiration, when vital capacity is between 0% and 75% of the
variables used to determine whether flow will be turbulent or total lung capacity [26]. At a vital capacity greater than 75%
laminar. Reynold’s number = 2Vrp/η, and values greater than of total lung capacity, it has been difficult to limit flow by
2300 generally indicate that flow will have a turbulent increasing pleural pressure in normal individuals [27].
component. Flow with a Reynold’s number greater than 4000 Therefore, traditional teaching indicated that early expiration
is completely turbulent [24]. is primarily limited by effort dependent muscle strength [27]. 477
Critical Care October 2005 Vol 9 No 5 Grinnan and Truwit
Figure 6 Figure 7
the trachea is turbulent, the resistance is inversely propor- lungs and chest wall. The inertia of the airway is also part of
tional to the radius of the trachea to the fifth power. Because impedance, but its contribution is negligible in respiratory
most endotracheal tubes are significantly smaller than the physiology. Impedance can be estimated through measure-
trachea, resistance to flow is significantly increased [25]. To ments of the work of breathing (WOB).
maintain flow, the pressure gradient must be appropriately
increased. With traditional modes of weaning from mechanical Work is defined as the product of pressure and volume (W =
ventilation (pressure support), a level of pressure support is P × V). In respiratory physiology, WOB describes the energy
maintained to overcome the resistance in the endotracheal tube. required as flow begins to perform the task of ventilation. The
Automatic tube compensation (ATC) is a method of reducing calculation of WOB is usually associated with inspiratory
the work needed to overcome the increased resistance of the effort, because expiration is generally a passive process.
endotracheal tube [33]. ATC is a flow triggered mode that However, in patients with air trapping or acute respiratory
varies pressure levels throughout the respiratory cycle. Studies failure, expiration can be an active process and can require
have found that the increased work of breathing caused by significant work. As the WOB increases, increased demand
high endotracheal tube resistance is decreased with ATC is imposed on the respiratory muscles. The respiratory
when compared with pressure support [33,34]. muscles of patients in acute respiratory distress will use an
increasing percentage of the cardiac output (which can
Least squares fit method induce ischemia in patients with coronary artery disease). As
As described above, traditional methods for measuring the demand increases, the respiratory muscles will eventually
respiratory mechanics require ventilator manipulation. fatigue. Bellemare and Grassino [37] first described the
Maneuvers such as inspiratory pause, expiratory pause, and diaphragmatic threshold for fatigue as the product of
airway occlusion have been used to measure variables such inspiratory time and the change in transdiaphragmatic
as compliance, resistance, and auto-PEEP. More advanced pressure with inspiration. When the diaphragmatic threshold
ventilators have built-in pressure transducers and pneumo- for fatigue exceeded 0.15, the task of ventilation could not be
tachographs to permit continuous measurement of pressure performed for longer than 45 min. As the diaphragm fatigues,
and flow. By incorporating these data into mathematical the accessory muscles of respiration are recruited, and the
models, such as the least squares fit method, measurements respiratory rate is increased. When fatigue leads to
of respiratory mechanics can potentially be monitored inadequate ventilation, carbon dioxide levels in the blood
continuously and without ventilator manipulation. Through increase and indicate a need for mechanical ventilation.
constant knowledge of flow, pressure, and volume (obtained
through the integration of flow), other variables (compliance, Usually, the goal of mechanical ventilation is to provide the
resistance, and auto-PEEP) can be resolved. vital organs with adequate oxygenation and ventilation while
decreasing the WOB. As the underlying disease process
Small series have compared the least squares fit method with resolves, the ventilator work is decreased and the patient’s
traditional methods, and have tielded promising findings. The WOB is increased until the patient is able to approximate the
least squares fit method correlates well with traditional WOB needed when extubated. From the above discussion, it
methods of measuring compliance, resistance, and auto- should be apparent that estimating the WOB in patients
PEEP [35,36], but it is not in widespread use at present. The breathing spontaneously and on mechanical ventilation can
technology for computing continuous measurements and be clinically important. WOB can be determined through
computing by the least squares fit method is not readily analysis of a PV plot, where work is the area under the curve.
available in most intensive care units. A potential weakness of Therefore, integrating the PV plot yields WOB. In such a plot,
the least squares fit method is that data are presented for a pressure represents the sum of the transpulmonary pressure
block of time, usually a single breath. If the start of inspiration gradient and the chest wall pressure gradient.
or the end of exhalation are not measured correctly by the
ventilator, the measurements will be incorrect [36]. Although In a spontaneously breathing patient, transpulmonary pressure
this does not present a major problem in paralyzed patients, can be measured by placing an esophageal balloon, because
interaction between patient and ventilator can skew the esophageal pressure (Pes) estimates pleural pressure.
mechanical measurements. Also, the mathematics of ‘fitting’ However, there is no direct method for measuring the chest
nonlinear patient breaths into linear mathematical models will wall pressure gradient. Three estimates of the chest wall
always create some degree of error. At this time the least gradient have been used to assess the WOB indirectly [1].
squares fit method of calculating respiratory mechanics is First, the chest wall gradient can be estimated using
intriguing, and further work will help to define its role in the computer analysis. The equation of motion (P = V/C + [Q × R])
intensive care unit. is the basis of computer analysis for pulmonary mechanics
[38]. When modified for the chest wall, resistive forces (Q × R)
Work of breathing and impedance can be eliminated, and the equation describes the elastic
Impedance to airflow includes the resistance to airflow as forces of the chest wall (Pcw = Vt/2Ccw) or work (product of
well as the force required to overcome the elasticity of the average inflation pressure and Vt): W = Vt2/2Ccw [1]. 479
Critical Care October 2005 Vol 9 No 5 Grinnan and Truwit
Determination of the WOB in patients on pressure modes of Traditionally, the PTP has been measured as the time integral
ventilation is more complicated [1]. If the patient is passive, of the difference between the esophageal pressure tracing
480 measurements can be made as explained above. However, if and the recoil pressure of the chest wall [40]. However, this
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Figure 9
Calculation of work per liter of ventilation (Pavg) in a passive patient on constant-flow mechanical ventilation. Pavg can be calculated by three
methods. (a) Dividing the integral of the airway pressure (Paw) by the inspiratory time (Ti). (b) Recording the airway pressure at the mid-inspiratory
time (Ti/2). (c) Calculating Pd – (Ps – Pex)/2, where Pd = peak inspiratory pressure, Ps = estimate of end-inspiratory pressure, and Pex = estimate
of end-expiratory pressure. Reprinted from [1] with permission from Elsevier.
method may not account for energy expenditure needed to these calculations, like the PTI, have not proven to be highly
overcome the load on inspiratory muscles at the beginning of predictive, limiting their use at the bedside. Other measures
inspiration in patients with dynamic hyperinflation [40]. The that are simpler to determine have proven to be more useful
traditional measurement may also fail to account for the and are discussed in the following part of the review.
energy needed to stop active expiration [40]. Determination
of ‘upper bound PTP’ and ‘lower bound PTP’ have enabled Discontinuation of mechanical ventilation
calculations of PTP throughout the respiratory cycle so that As stated above, successful discontinuation of mechanical
total energy expenditure can be approximated (Fig. 10). ventilation will depend on close assessment of the patient’s
respiratory mechanics while on the ventilator. In addition to
The pressure time index (PTI) expands on the PTP. It is deter- assessing the mechanics, there are many other
mined by the following equation [1,41]: PTI = (Pavg/MIP) × considerations. First, it is important to recall the indication for
(Ti/Ttot), where MIP is the maximal inspiratory pressure that mechanical ventilation and intubation. Some indications (e.g.
can be generated by an individual, Ti is the duration of altered mental status, upper gastrointestinal bleed
inspiration, and Ttot is the duration of the respiratory cycle. threatening airway safety, inability to handle secretions,
By including the measurements used in the PTP, the PTI also recurrent aspiration, hemoptysis) may be accompanied by
yields a more reliable estimate (compared with WOB) of the normal respiratory mechanics, but mechanical ventilation may
total energy expended in respiration. Addition of the MIP to be necessary until the indication for intubation has been
the calculation of PTI permits determination of the respiratory addressed. For example, a patient with severe alteration in
effort as related to respiratory strength. MIP can easily be mental status requiring intubation for airway protection should
calculated at the bedside of a mechanically ventilated patient have improved mental status, require suctioning less than
with the use of a one-way valve [1]. Inclusion of the Ttot in the every 2 hours, be able to follow basic commands, and have a
PTI permits the duration of energy expenditure in the cough and gag reflex before extubation. However, in patients
respiratory cycle to be compared with the duration of rest. intubated for respiratory failure, assessment of respiratory
The PTI, much like the diaphragmatic threshold for fatigue of mechanics before extubation can help to predict the success
Bellemare and Grassino [37], has been used to predict the of extubation.
likelihood of subsequent respiratory fatigue and the need for
intubation [41,42]. Conversely, it has been applied to Weaning trials are recommended for patients with prolonged
prediction of successful discontinuance of mechanical intubation or cardiopulmonary causes for intubation [45]. In
ventilation in patients weaning from mechanical ventilation general, a weaning trial involves reducing the work performed
[43,44]. A weakness of the PTI in determining success of by the ventilator while monitoring for evidence of fatigue or
extubation is that it does not incorporate the respiratory rate. altered gas exchange. There are several different ways to
A common reaction of patients in respiratory failure is to perform a weaning trial. Pressure support ventilation is a
increase the respiratory rate and to decrease Vt in order to mode of ventilation characterized by patient triggered
decrease the subjective sensation of dyspnea. In such ventilation with both an inspiratory pressure level (IPL) and
patients, the PTI would decrease as the Vt decreased. PEEP. The IPL and PEEP are gradually decreased to minimal
levels before extubation. Although exceptions occur, the IPL
Quantifications of the inspiratory WOB have also been should usually be less than 12 cmH2O and the PEEP should
applied to prediction of weaning success. Unfortunately, be less than 7 cmH2O before extubation is attempted. 481
Critical Care October 2005 Vol 9 No 5 Grinnan and Truwit
Figure 10
Energy expenditure determined by the pressure time product (PTP) in a patient on pressure support ventilation. In all graphs, the continuous line is
esophageal pressure (Pes) and the interrupted line represents the estimated recoil pressure of the chest wall (Pescw). (a) Pressure tracings have
been superimposed so that Pescw is equal to Pes at the onset of the first inspiratory effort, and the integrated difference (hatched area) represents
the upper bound PTPinsp. (b) Pressure tracings have been superimposed so that Pescw is equal to Pes at the first moment of transition from
expiratory to inspiratory flow, and the integrated difference (hatched area) represents lower bound PTPinsp. (c) Pressure tracings are
superimposed so that Pescw is equal to Pes at the second moment of transition from expiratory to inspiratory flow, and the integrated difference
(hatched area) represents upper bound expiratory PTP (PTPexp). (d) Pressure tracings have been superimposed so that Pescw is equal to Pes at
the onset of the second inspiratory effort, and the integrated difference (hatched area) represents lower bound PTPexp. With permission from
Jubran et al. [56].
Usually, the IPL is under 7 cmH2O, with PEEP below In 1995, Esteban and coworkers [48] investigated different
5 cmH2O. Intermittent mandatory ventilation is a mode that strategies for weaning patients with respiratory distress. The
provides fully supported, volume controlled breaths with four weaning strategies compared were pressure support,
unsupported, patient triggered breaths. The respiratory rate intermittent mandatory ventilation, a once daily SBT, and
of the supported breaths is gradually decreased to permit the intermittent SBTs (more than two per day). With a once daily
patient to increase their WOB gradually. In general, respira- SBT, the rate of successful weaning was superior to the rates
tory rates less than 4/min tolerated for 2 hours yield a with pressure support ventilation and intermittent mandatory
favorable prognosis on extubation [46]. ventilation, and equivalent to the rate with multiple daily trials.
Most intensive care units have adopted this strategy for
Several methods of weaning further reduce the WOB and are difficult-to-wean patients.
termed spontaneous breathing trials (SBTs). With a
When a patient is on a SBT, there are several mechanical
continuous positive ariway pressure (CPAP) trial, an
variables that can help to determine whether extubation is
intubated patient is allowed to breathe spontaneously while
appropriate or will likely result in reintubation. The rapid
receiving CPAP. As the patient is still connected to the
shallow breathing index (RSBI) has been widely used to help
ventilator, mechanics can easily be measured. The size of the
to predict subsequent respiratory failure in patients weaning
endotracheal tube will influence the level of CPAP required to
from mechanical ventilation. Measured as the respiratory rate
overcome the resistance of the tube. It is our experience that,
divided by the Vt in liters (RSBI = RR/Vt), it has been shown
in patients with heart failure and an endotracheal tube above
to correlate well with the WOB and the PTI in mechanically
7.0 mm in diameter, a 30 min trial of CPAP at 0 cmH2O may
ventilated patients [49]. The extreme ease of its calculation
help to determine whether a patient will develop pulmonary
has made this measurement popular. The RSBI should be
edema requiring reintubation following extubation. At our
calculated during an unassisted breathing trial. In patients
institution, with the use of impedance cardiography, we found
under 70 years of age, a RSBI below 105 during a weaning
that patients who fail a CPAP trial at 0 cmH2O have a
trial yields an 80% positive predictive value for successful
significant decrease in cardiac output compared with patients
extubation [49]. In patients older than 70 years, a RSBI under
who passed the SBT [47]. In a trach collar trial, a patient with
130 during a weaning trial still yields a positive predictive
a tracheostomy is removed from the ventilator to breathe with
value of 80% for successful extubation [43].
supplemental oxygen. A T-piece trial involves placing a ‘T’
shaped tube, connected to an oxygen source, over the Alternatively, the time to recovery of minute ventilation
endotracheal tube so that the patient may breathe following a trial of weaning from mechanical ventilation has
482 spontaneously for a set amount of time. been used as a predictor of successful extubation. Minute
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ventilation equals the respiratory rate multiplied by the Vt ments are readily available at the bedside and can be used to
(Ve = RR × Vt). During a SBT, the minute ventilation will assist with diagnosis and treatment of various illnesses.
commonly increase as the patient attempts to manage the Measurement of respiratory mechanics is most widely done in
increased workload. When the SBT has concluded and the patients receiving mechanical ventilation. In mechanically
ventilator work is increased, the minute ventilation will ventilated patients, measurements of mechanics can provide
gradually return to its baseline. The rate of return to baseline information about the severity of disease, the response to
of minute ventilation is thought to estimate the respiratory treatment, and the safety of ventilator discontinuation.
reserve, and it has been found to help with prediction of Mechanics have also become a treatment modality, because
successful extubation. In a recent study, the minute ventilation measuring plateau pressures and making appropriate
recovery time was found to be significantly shorter in patients ventilator adjustments can lead to improved outcomes in
who were successfully extubated than in those who required selected patients receiving mechanical ventilation. We
repeat intubation (P < 0.01) [50]. anticipate that, as technology improves and the measurement
of mechanics moves toward automation and ventilator
In addition to these measures of respiratory mechanics, several algorithms, the use of respiratory mechanics at the bedside
determinants of respiratory muscle strength have been will increase further.
developed. The negative inspiratory force is a marker of the
force that a patient can generate against an occluded valve. Competing interests
Generally, this requires 1 s of inspiratory effort against the The author(s) declare that they have no competing interests.
occluded valve, and the most negative of three measurements
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