Journal of Critical Care (2012) 27, 37–44

Manual compression of the abdomen to assess expiratory

flow limitation during mechanical ventilation☆
Malcolm Lemyze MD a,⁎, Raphael Favory MD a , Isabelle Alves MD a ,
Thierry Perez MD b , Daniel Mathieu Pr a
a
Department of Respiratory and Critical Care Medicine, Calmette Hospital, Lille II University Hospital, Lille, 59000, France
b
Department of Lung Function, Calmette Hospital, Lille, 59000, France

Keywords:
Abstract
Chronic obstructive
Purpose: The aim of this study was to evaluate the manual compression of the abdomen (MCA) during
pulmonary disease;
expiration as a simple bedside method to detect expiratory flow limitation (EFL) during daily clinical
Dynamic pulmonary
practice of mechanical ventilation (MV).
hyperinflation;
Methods: We studied 44 semirecumbent intubated and sedated critically ill patients. Flow-volume loops
Expiratory flow limitation;
obtained during MCA were superimposed upon the preceding breaths and recorded with the ventilator.
Intrinsic positive end-
Expiratory flow limitation was expressed as percentage of expiratory tidal volume without any increase
expiratory pressure;
in flow during MCA (MCA [%VT]). In the first 13 patients, MCA was validated by comparison with the
Mechanical ventilation
negative expiratory pressure (NEP) technique. Esophageal pressure changes during MCA and intrinsic
positive end-expiratory pressure were also recorded in all the patients.
Results: Manual compression of the abdomen and NEP agreed in all cases in detecting EFL with a bias
of −0.16%. Percentage of expiratory tidal volume without any increase in flow during MCA is highly
correlated with percentage of expiratory tidal volume without any increase in flow during NEP (n = 13,
P b .0001, r2 = 0.99) and intrinsic positive end-expiratory pressure (n = 44, P b .001, r2 = 0.78), with a
good repeatability (n = 44; within-subject SD, 5.7%) and reproducibility (n = 13; within-subject SD,
2.41%). Two third of the patients were flow limited, among whom one third had no previously known
respiratory disease.
Conclusions: Manual compression of the abdomen provides a simple, rapid, and safe bedside reliable
maneuver to detect and quantify EFL during mechanical ventilation.
© 2012 Elsevier Inc. All rights reserved.

☆
All authors have read the manuscript and declare no financial
support, no potential conflict of interest, no prior publication or concurrent
submission, and no copyright constraints.
⁎ Corresponding author. Service de Réanimation Polyvalente, Hôpital
Calmette, Bd du Pr Jules Leclercq, 59000 Lille, France. Tel.: +33 3 20 44 44
95; fax: +33 3 20 44 50 94.
E-mail address: malcolmlemyze@yahoo.fr (M. Lemyze).
1. Introduction
In many respiratory diseases such as chronic obstructive
pulmonary disease (COPD), the destruction of lung paren-
chyma is responsible for a loss of the alveolar septa that
normally support the small airways and keep them open [1].
As a result, the more the pleural pressure increases, the more
poorly supported airways are compressed during expiration.

0883-9441/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcrc.2011.05.011
38
This dynamic compression of the small airways during
expiration makes it impossible for the subject to increase its
expiratory flow beyond its resting value [2]. This phenom-
enon contributes to expiratory flow limitation (EFL). It leads
to dynamic pulmonary hyperinflation promoting airway
closure, air trapping, and intrinsic positive end-expiratory
pressure (PEEPi) [3]. Dynamic pulmonary hyperinflation has
deleterious consequences on the respiratory and circulatory
systems. From a respiratory point of view, it increases work
of breathing [4], impairs inspiratory muscle function [5], and
is one of the main mechanisms explaining dyspnea in patients
with COPD [6]. During mechanical ventilation (MV), it is
associated with patient-ventilator asynchrony, delaying
weaning from the ventilator [7] and discharge from the
intensive care unit (ICU) [8]. It can also lead to detrimental
hemodynamic effects such as depressed cardiac output and
reduced peripheral blood flow [3]. Gay et al [9] previously
showed that detection of EFL during MV was a key
information because the effect of positive end-expiratory
pressure (PEEP) on respiratory system mechanics depends on
the presence or not of EFL. Therefore, many methods are put
forward to detect EFL in mechanically ventilated patients:
removal of external PEEP, if present [10]; addition of
resistances to the expiratory circuit of the ventilator [11];
forced oscillation technique [12]; and application of negative
expiratory pressure (NEP) at the airway opening during
expiration [13]. However, none of them are easy to achieve in
daily clinical practice, especially for critically ill patients
receiving MV. We investigated a simple bedside maneuver,
the manual compression of the abdominal wall (MCA),
already validated in spontaneously breathing patients with
COPD [14], to assess EFL in mechanically ventilated patients
in the ICU by comparison with the NEP.
2. Methods
2.1. Eligibility
Patients admitted in a 10-bed ICU of a tertiary university
hospital for any medical reason requiring invasive MV and
sedation were prospectively included from December 2007
to April 2008.
The exclusion criteria were current pregnancy; recent
abdominal surgery; or any acute intra-abdominal disease,
hemodynamic instability, severe hypoxemia defined as
PaO2/FIO2 less than 200, and presence of patient-
ventilator asynchrony.
Anthropometric data, medical history of respiratory
disease, risk of death assessed by the Simplified Acute
Physiology Score 2 [15], and duration of MV were recorded.
Diagnosis of COPD was based on criteria detailed in the
GOLD [Global Initiative for Chronic Obstructive Lung
Disease] guidelines [16]; asthma was defined according to
the Global Initiative for Asthma guidelines [17]. A body
M. Lemyze et al.
mass index (BMI) above 30 kg/m2 was classified as obesity
according to the World Health Organization's criteria [18].
The protocol was approved by the local ethics committee,
and informed consent was obtained from the patients or next
of kin.
2.2. Measurements' conditions
The patients, placed in the semirecumbent position (upper
half of the bed raised by 45°), were intubated with a cuffed
endotracheal tube (Mallinckrodt, Athlone, Ireland) with inner
diameter varying from 7.0 to 8.5 mm. All of them were lightly
sedated with midazolam and remifentanyl according to the
protocol used in our ICU. Infusion rate was adapted by the
nursing team on the Ramsay sedation scale to obtain a 3
sedation level [19]. Controlled MV (Evita 2 dura or Evita 4;
Dräger, Lübeck, Germany) was performed using a volume-
controlled mode, delivering constant flow during insuffla-
tion. Baseline ventilatory settings were kept constant
throughout the experiment. For all patients, PEEP was
initially set to 0 on the ventilator. Airway pressure (Paw),
flow (V̇ ), and volume (V) were measured with the ventilator
built-in pressure transducer and flowmeter connected to a
personal computer. VentView 2.n software (version 01.01;
Dräger Medizintechnick, Lübeck, Germany) enabled acqui-
sition and continuous recording of Paw, V, and V̇ signals.
Expiratory muscle relaxation was confirmed by uniform
sequential recordings of Paw, V, and V̇ and absence of
negative deflections of Paw or other visible signs of patient-
ventilator asynchrony. Arterial blood gases were measured
with a blood gas analyzer (ABL 725; Radiometer, Copenha-
gen, Denmark) that was calibrated several times a day.
2.3. Respiratory mechanics
Static PEEPi (PEEPi,stat) was determined using the end-
expiratory occlusion maneuver as previously described in
detail [11].
2.4. Manual compression of the
abdomen maneuvers
Manual compression of the abdomen was achieved as
described by Ninane et al [14] by a single investigator. He put
his right hand on the abdominal wall, with the palm on the
umbilicus oriented perpendicularly to the axis between the
xyphoid process and the pubis. After a short period allowing
recognition of the expiratory phase, the investigator exerted,
as soon as the insufflation was finished, a firm but gentle
compression of the abdomen in an anteroposterior direction.
This compression was maintained throughout expiration. To
ensure that the maneuver was associated with an increase in
the expiratory-driving pressure, esophageal pressure and Paw
were continuously recorded at a digitizing frequency of 100
Hz. A saline solution–filled nasogastric tube and the filter of
MCA to assess EFL during MV 39

the endotracheal tube were each therefore connected to a
transducer and pressure analyzer [20]. Appropriate placement
of the esophageal tube was verified by recording small
pressure variations synchronous to heart rate, confirming its
position behind the left atrium [21].
The V̇-V loops obtained during MCA maneuver and the
immediately preceding breaths were superimposed and
recorded via the ventilator. The first one acts as the control
curve. Patients were considered as flow limited (FL) when
all or part of the expiratory V̇-V curve during MCA were
superimposed on the control curve. On the contrary, if the
expiratory flow during MCA was higher than under control
conditions, the subject was classified as having no EFL
(Fig. 1). The FL portion was expressed as a percentage of
the tidal volume and was called MCA (%VT). Its value
corresponds to the average of 3 consecutive measurements.
2.5. Negative expiratory pressure method
The endotracheal tube was connected through a low
resistive filter to a Hyp'air Compact pneumotachograph

Fig. 1 Comparison of the superimposed flow-volume (V-̇ V) loops obtained, respectively, with the MCA (on the left) and with the NEP
technique (on the right) for 2 patients. Expiratory phase is shown on the upper part of the curves, and insufflation phase is at the bottom. For
NFL patient 1, MCA and NEP both demonstrate a normal increase in flow during the whole expiration. Conversely, for FL patient 7, the
expiratory part of the V̇-V loops achieved with NEP as with MCA rapidly meet the control V̇-V loops, defining EFL. exp indicates expiratory
phase; ins, insufflation phase.
40 M. Lemyze et al.

MCA maneuvers were successively done in each of the 44

Fig. 2 Concordance analysis plots showing bias (thick line) and
limits of agreement (dashed lines) between the 2 methods, MCA
and NEP. Within the 13 patients, 6 are plotted at the point (0,0).
(Medisoft, Dinan, Belgium) and a T tube with a 15-mL dead
space. Assessment of EFL using the NEP technique was
achieved as previously described with a negative-pressure
source set at −5 cm H2O by an observer blinded for MCA
maneuver results [13]. V̇-V curve recorded during the NEP
maneuver was superimposed upon the preceding breath.
Expiratory flow limitation was expressed as percentage of
expiratory tidal volume during which no increase in flow was
found. Three consecutive measurements were performed in
each of the tested patients.
patients by the same investigator.
Results were expressed in mean ± SEM. Correlation
between EFL values, obtained by MCA and NEP, respec-
tively called MCA (%VT) and NEP (%VT), was performed
with Pearson rank correlation test (SPSS for Windows 9.0
[Chicago, IL, USA]). The graphic method described by
Bland and Altman [22] was used to compare the first
measure of MCA and NEP by plotting the differences
between the 2 techniques against their averages (Fig. 2).
Using a 1-way analysis of variance for repeated measures,
repeatability was assessed by calculating the within-subject
SD (SDw) corresponding to the square root of average
variance of the 3 consecutive measures of MCA (%VT) in the
44 patients [23]. Repeatability of MCA-induced esophageal
pressure change (ΔPes) performed by a single investigator
and reproducibility of MCA maneuvers between the 5
investigators in the first 13 patients were assessed using the
same method. Nonparametric Mann-Whitney U test was
used to compare the quantitative variables within FL and
non-FL (NFL) patients, whereas Fisher exact test was used
for qualitative variables. For all tested variables, P b .05
were considered statistically significant.
3. Results

We have studied 44 patients (28 men) 56 ± 2.6 years old

2.6. Study design and data analysis
Expiratory flow limitation was both assessed by MCA and
NEP in the first 13 patients enrolled. To assess reproducibility
(interobserver variation) of the MCA maneuver in these 13
patients, MCA was successively carried out by 5 investigators
who had never been accustomed to the maneuver before the
study. To evaluate repeatability (intraobserver variation), 3
(minimum, 22; maximum, 87). Their main clinical charac-
teristics are summarized in Table 1. They had been under
MV for 4.7 ± 0.8 days (minimum, 1; maximum, 22). Mean
Simplified Acute Physiology Score 2 was 41.7 ± 1.9
(minimum, 15; maximum, 74). Twenty of them had a
medical history of bronchial disease, diagnosed as COPD for
17 of them and as asthma for 3 of them. Mean BMI reached
29.6 ± 1.2 kg/m2, and 21 patients were classified as obese.

Table 1 Respiratory parameters of the 13 patients tested with MCA and NEP
Patient number VT RR TE PaO2/Fio2 PEEPi,stat NEP MCA ΔPes
(L) (breath/min) (sec) (cm H2O) (%VT) (%VT) (cm H2O)
1 0.55 18 2.53 496 0.4 0 0 8.9
2 0.5 18 2.63 317.5 0.5 0 0 10.7
3 0.5 18 2.63 474 1.2 0 0 13
4 0.5 20 2.30 262.5 1.2 0 0 7.9
5 0.5 20 2.35 242.5 1.2 0 0 10.6
6 0.5 18 2.68 547 0.8 0 0 12.5
7 0.55 18 2.63 242.5 4.9 48.7 44.4 7.2
8 0.5 18 2.53 463 6.2 56.3 56.6 20.3
9 0.5 18 2.68 389 3.1 63 59.2 14
10 0.55 24 1.70 326 10.0 87.7 82.6 15.4
11 0.4 18 2.78 370 15.2 90.3 84.9 34.3
12 0.5 16 3.1 255 16.2 97 88 19
13 0.5 18 2.68 411 5.9 87.3 90.6 24.4
VT indicates tidal volume; RR, respiratory rate; TE, expiratory time.
MCA to assess EFL during MV 41

3.1. Validation of MCA Table 2 Comparison of the NFL with the FL patients
Parameters NFL (n = 13) FL (n = 31) P
Respiratory characteristics of the 13 patients who were
Age (y) 40.6 ± 4 62.4 ± 2.5 b.001
tested with MCA and NEP maneuvers are presented in
Male (%) 10 (76) 18 (58) NS
Table 1. A significant correlation was found between EFL, BMI 23.9 ± 1.1 32 ± 1.5 b.001
quantified by MCA, called MCA (%VT), and EFL Obesity (n) 1 20 b.001
measured with the NEP technique, NEP (%VT) (n = 13, Previous smokers (n) 3 25 b.001
r2 = 0.99, P b .01). There was a perfect agreement COPD (n) 0 17 b.001
regarding the presence or absence of EFL between NEP Asthma (n) 0 3 b.001
and MCA. No patient without EFL recorded by NEP was SAPS 2 36.5 ± 4.1 43.8 ± 2.1 NS
FL as assessed by MCA and inversely. As shown in Figs. 2 Duration of MV (d) 10.5 ± 1.6 23.7 ± 4.2 .05
and 3, quantitatively, agreement between the 2 techniques ETT ID (mm) 7.5 ± 0.09 7.4 ± 0.07 NS
was also very good (n = 13; bias, −0.16% ± 3.9%; 95% VE (L/min−1) 9.4 ± 0.2 9.1 ± 0.2 NS
RR (breath/min−1) 18.8 ± 0.4 19.2 ± 0.3 NS
limits of agreement, −7.8%-7.5%). There was a clinically
TE (s) 2.5 ± 0.07 2.4 ± 0.05 NS
acceptable repeatability of MCA (%VT) in each subject
VT (mL/kg−1) 7.3 ± 0.27 8.2 ± 0.26 .03
(n = 44; SDw, 5.7%; P = .33). Despite large variations of PEEPi,stat (cm H2O) 0.9 ± 0.1 7.7 ± 0.7 b.0001
the esophageal pressure among the 5 investigators (n = 13;
SAPS 2 indicates Simplified Acute Physiologic Score 2; ETT ID,
SDw, 4.09 cm H2O; P b .0001), reproducibility of MCA endotracheal tube internal diameter; VE, minute ventilation.
(%VT) was also good (n = 13; SDw, 2.41%; P = .67).
No complication happened during the study because of
the MCA maneuver. noninvasive, bedside method to detect and quantify EFL
during MV and (2) MCA may easily reveal EFL in many
3.2. Comparison of the NFL (n = 13) with the FL ventilated patients in ICU, especially in patients without any
patients (n = 31) previously known respiratory disease.
Expiratory flow limitation assessment by the method
Among the 44 patients, 31 had EFL. All patients with a originally described by Hyatt [2] in 1961 and based on the
medical history of obstructive respiratory disease and all but comparison of the resting V̇-V curve with those obtained by a
1 of the 21 obese patients were FL. Eleven FL patients had forced vital capacity maneuver is not appropriate for patients
no previously known respiratory disease. Only 4 patients in the ICU. First, because of the gas compression during the
demonstrated EFL without COPD, obesity, or asthma. Main forced vital capacity maneuver, volumes have to be
clinical and physiologic characteristics of FL patients measured in a plethysmography cabin [24]. Second,
compared with NFL patients are shown in Table 2. Fig. 4 expiratory flow depends on the volume and time history of
illustrates that PEEPi,stat correlates well with MCA (%VT) the preceding breath [25]. Because volume and time history
(n = 44, r2 = 0.78, P b .0001). Note that none of the patient are very different between the resting inspiration and the one
with PEEPi less than 1.6 cm H2O demonstrated EFL. obtained during forced vital capacity maneuver, EFL
detection by the comparison of the resting V̇-V loop with
the maximal one often leads to erroneous conclusions.
4. Discussion Finally, expiratory flow during a forced vital capacity
maneuver through an endotracheal tube is clearly limited
The main results of the present study could be by the diameter of the tube [26].
summarized as (1) MCA appears to be a simple, safe,

Fig. 4 Correlation between dynamic pulmonary hyperinflation,

Fig. 3 Comparison between FL volume assessed by MCA and assessed by PEEPi,stat, and EFL, assessed by percentage of FL tidal
NEP in 13 patients showing very similar results. volume during MCA(%VT) (n = 44, P b .0001, r2 = 0.78).
42
To avoid these numerous pitfalls, another technique, the
application of an NEP, has been introduced and validated
during MV by concomitant determination of isovolume
flow-pressure relationships [13]. The NEP technique does
neither require performance of forced vital capacity
maneuvers from the patient nor a body plethysmograph.
Although NEP method is a noninvasive technique specially
fitted for subjects receiving MV, it requires an expensive
material added on the ventilator [13].
In this study, MCA, a much simpler method, was
compared with NEP, considered as a reference method to
detect EFL. During MV, MCA mimics a forced expiratory
maneuver that results in an increased pressure gradient
driving the expiratory flow, with strictly superimposable
conditions regarding the preceding control breath. This
lasting characteristic of the MCA technique allows the
method to be freed from the limits discussed above. A
limitation of this study may be the small number of patients.
However, to our knowledge, none of the previously validated
methods of EFL assessment have been conducted in a greater
number of ventilated patients [11,13]. In the ICU, MCA is
really easy to achieve in the real conditions of the daily
clinical practice of MV because the only device it needs is a
ventilator. Indeed, most modern ventilators used in the ICU
are equipped with a reliable pneumotachograph, and super-
imposed flow-volume loops can be directly displayed on the
ventilator screen. Manual compression of the abdomen does
not require collaboration from the patient, which is an
essential condition for any method of measurements used in
critically ill patients. However, it may be argued that MCA
lacks standardization. The agreement between the results
obtained with MCA and NEP methods and the high
correlation between EFL magnitude determined by the 2
methods ensures that MCA-assessed EFL is reliable. In our
study, change in esophageal pressure value (ΔPes) resulting
from MCA was not reproducible from a maneuver to another
even when performed by the same investigator on the same
patient. Nevertheless, the level of EFL taken as MCA (%VT)
from 1 maneuver to another in the same subject remains with
a clinically acceptable repeatability and reproducibility
whatever the real level of the ΔPes achieved. Provided that
a minimal driving pressure is achieved by either an NEP or a
MCA, the same results are obtained in terms of detection and
titration of EFL. Manual compression of the abdomen has the
definite advantages of being quicker, as effective and cheaper
than the NEP technique because it requires no special device
added to the ventilator and no adjustments of the ventilator
settings. Finally, MCA can easily be achieved without the use
of muscle relaxant. On the contrary, MCA has been
successfully applied in spontaneously breathing subjects
[14]. In consequence, MCA should also be applicable during
any type of triggered MV such as pressure support.
Expiratory flow limitation is a hallmark finding of
patients with obstructive lung disease [2]. But one interesting
finding in our study is that some critically ill patients
demonstrate EFL during MV without any previously known
M. Lemyze et al.
obstructive respiratory disease. Among the 44 patients of the
present study, 11 matched these criteria. Some of them are
elderly or obese patients. Closing volume is known to
increase linearly with advancing age, especially in the supine
position [27]. In addition, half of our population consisted of
obese patients, and all but 1 presented EFL. Low tidal
volume ventilation of obese subjects promotes small airways
occlusion and EFL leading to dynamic pulmonary hyperin-
flation and PEEPi, especially in the supine position [28].
Regardless of age and weight, EFL may develop as an acute
condition during MV because of the reduction of the
bronchial caliber. Two of them—a 45-year-old man and a
48-year-old woman, both nonsmokers—had initially re-
ceived large amount of fluid because of septic shock caused
by extensive cellulitis. In an 87-year-old woman with a
medical history of congestive heart failure and admitted to
the ICU for septic shock, EFL may result, at least in part,
from her great age and acute pulmonary edema. In the last
one—a 44-year-old man who developed postanoxic enceph-
alopathy after an attempted suicide by hanging—no
causative factor can be isolated. Indeed, bronchial edema
may be present in critically ill patients who received large
amounts of fluid during the initial resuscitative period of
sepsis but also because of sepsis-associated acute lung injury
or ventilator induced lung injury [29]. Manual compression
of the abdomen may be useful as a quick and simple
technique to detect EFL especially when the clinician would
not have expected the patient to be FL.
Intrinsic PEEP measured in static conditions (with end-
expiratory occlusion maneuver) overestimates the one
measured in dynamic conditions during MV [30]. Abnormal
contraction of the abdominal muscles during expiration, even
clinically undetectable, may overestimate dynamic PEEPi
value [31]. Although both palpation of the abdominal wall
attested relaxation of the expiratory muscles and stable
pressure, volume, flow curves, and a plateau in Paw were
constantly observed in our study, postinspiratory muscle
contraction cannot be totally ruled out. This may explain the
greater dispersion of measured PEEPi,stat value from those
predicted by the regression equation using MCA (%VT) in
the patients with the most severe EFL. However, none of the
patients with measured PEEPi,stat below 1.6 cm H2O had
EFL. Consequently, when a patient shows no pulmonary
hyperinflation as demonstrated by a PEEPi approaching 0, it
is likely that looking for EFL is useless. In that case, MCA
should not be performed.
Conversely, whenever dynamic pulmonary hyperinflation
is suspected during MV, detection of EFL is paramount
because EFL may lead to incomplete lung emptying and
promotes end-expiratory air trapping. In our study, EFL was
constantly present when PEEPi,stat exceeded 1.6 cm H2O.
Detection of EFL is a real challenge and enables to
distinguish 2 different clinical situations. First, dynamic
pulmonary hyperinflation without EFL often results from
inappropriate ventilator settings [32]. In that case, the simple
reduction of the tidal volume or increase in expiratory time
MCA to assess EFL during MV
may be sufficient to relieve overinflation. End-expiratory
lung volume progressively increases when external PEEP is
incrementally applied in such patients; thus, worsening
hyperinflation [9,33]. Manual compression of the abdomen
may help the clinician to quickly unmask these pitfalls of
MV. In our study, FL patients had greater PEEPi,stat than
NFL patients. In the 2 groups, the patients had similar internal
diameter of the endotracheal tube and the same minute
ventilation and expiratory time, and no PEEPi was measured
in the NFL patients. This suggests that, for our patients, EFL
accounts for a large part of their dynamic pulmonary
hyperinflation. The significant correlation between MCA
(%VT) and PEEPi,stat confirms this hypothesis. In this
second situation, when dynamic pulmonary hyperinflation
couples with EFL, external PEEP can unload the patient's
inspiratory muscles; thus, reducing work of breathing [34].
The effect of external PEEP on respiratory system mechanics
has been elegantly explained by the analogy of a waterfall,
where PEEPi acts as the height of the waterfall and the
downstream level represents external PEEP [35]. Referring to
this monocompartimental model, it seems obvious that
external PEEP can be increased to the level of PEEPi without
affecting alveolar pressure. However, the highly nonhomo-
geneous structure of the lung must be kept in mind, and
PEEPi,stat and MCA (%VT) as well remain mean values of all
the different lung units. In some patients, extrinsic PEEP may
lead to deleterious hemodynamic consequences especially
when PEEP is set over 85% of the measured PEEPi, as it can
increase end-expiratory lung volume [36]. In others, a
paradoxical response may occur when external PEEP relieves
overinflation, resulting in a diminished functional residual
capacity, total PEEP, and plateau pressures and an increase in
isovolume expiratory flow [37]. Still unpredictable, the
response to PEEP needs to be addressed individually but
highly depends on the presence or absence of EFL.
In conclusion, MCA provides a simple and rapid bedside
reliable maneuver to safely detect and to quantify EFL during
MV. It requires neither the cooperation of the patient nor any
special device added to the ventilator. Finally, MCA is a
particularly well-adapted method for a daily clinical use on
mechanically ventilated patients in the ICU.
Acknowledgment
The writers thank Dr Aurélie Guiot (MD University
Hospital of Rouen) for her invaluable assistance with the
statistical analysis of data.
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