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Understanding The Collapse of Lungs With Shorter Time Constants and How APRV Prevents It
Understanding The Collapse of Lungs With Shorter Time Constants and How APRV Prevents It
Introduction
Restrictive lung diseases, such as respiratory distress syndrome
(RDS) in neonates, are characterized by reduced lung compliance
and increased susceptibility to alveolar collapse. Effective
ventilation strategies are crucial for managing these conditions and
preventing further lung injury. Traditional ventilation methods often
struggle to maintain alveolar stability, leading to frequent episodes of
collapse and derecruitment.
τ = R×C
The volume of air (V) in the lungs during exhalation can be modeled
exponentially, where the rate of change of volume over time is
proportional to the volume itself:
V(t) = V0 × e−t/τ
where:
Vnormal(t) = V0 × e−t/τ 1
Vrestrictive(t) = V0 × e−t/τ 2
Since τ1 > τ2, the magnitude of dV/dt for restrictive lungs is greater
than for normal lungs, indicating a faster rate of emptying:
Principles of APRV
The key is that the PHigh is held for a longer duration to promote
alveolar recruitment and stability, while the brief PLow allows for
partial exhalation and CO2 removal.
PHigh Phase:
During PHigh, the alveolar volume (V) increases as the lung is held at
a high pressure for a prolonged period:
where:
PLow Phase:
where:
1. Prolonged PHigh:
THigh ≫ τPHigh
This relationship ensures that the alveoli remain open long enough to
achieve adequate recruitment.
2. Brief PLow:
TLow ≪ τPLow
Consider the volume change during the PHigh and PLow phases:
During PHigh:
During PLow:
VPHigh(t) ≈ V0 + ΔVrecruitment
Key Concepts
3. Flow-Dependent Resistance:
• Because the artificial airway produces a nonlinear,
flow-dependent resistive load, the highest flow
resistance occurs at the initial portion of the
release phase.
• TLow or the release phase should be terminated at
the T-PEFR (peak expiratory flow rate termination
point) rapidly before the flow-dependent expiratory
load is dissipated, resulting in maintained end-
expiratory volume and pressure.
where:
Expiratory Flow Rate: The flow rate F(t) at any time t is given by:
Determining T-PEFR
The peak expiratory flow rate (PEFR) occurs at t=0 and can be
expressed as:
PEFR = V0/τ
The T-PEFR, the time at which the expiratory flow rate has decreased
to a specific percentage of PEFR (typically 50-75%), is determined
by:
V0/τ × e−T /τ
PEFR
= 0.75 × V0/τ
e−T /τ
PEFR
= 0.75
−TPEFR/τ = ln(0.75)
TPEFR = −τ × ln(0.75)
TPEFR ≈ 0.287 × τ
By setting TLow in this manner, the lung volume at the end of the
release phase is maintained, preserving EELV and preventing
derecruitment. This approach ensures that the rapid phase of
expiratory flow is terminated before significant volume loss occurs,
thereby maintaining alveolar stability and preventing collapse.
F(t) = F0 × e−t/τ
The volume of air exhaled beyond T-PEFR can be integrated over time
from TPEFR to the end of the expiration:
VERLV = F0 × τ × e−T /τ
PEFR
VERLV = F0 × τ × e−0.287
VERLV ≈ F0 × τ × 0.75
Conclusion
By understanding the mathematical relationship between the time
constant, T-PEFR, and the expiratory flow pattern, clinicians can
optimize TLow settings in APRV to maintain appropriate lung
volumes and pressures. This approach leverages physiological
principles to enhance patient outcomes, particularly in restrictive
lung diseases.
References
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