Abstract
Objective
To examine the circulatory and respiratory effects of breathing pattern in patients with chronic obstructive pulmonary disease (COPD) and dynamic hyperinflation (DH) during controlled mechanical ventilation.
Design
Prospective, controlled, randomized, non-blinded study.
Setting
Respiratory intensive care unit of a university hospital.
Patients
Nine patients with acute respiratory failure and DH due to acute exacerbations of COPD.
Interventions
Keeping tidal volume and total breath duration (TTOT) constant, patients were ventilated at six different values of expiratory time (TE). TE changes were randomly induced by alterations of constant inspiratory flow\(\left( {\dot V_1 } \right)\) and/or end-inspiratory pause (EIP). Patients were studied at three levels of\(\dot V_1 \)(0.93±0.08, 0.72±0.06 and 0.55±0.04 l/s, mean ±SE), with and without EIP (10% of TTOT).
Measurements and results
Lung volumes, airflows, airways pressures, oxygenation indices and dead space were measured. Alveolar pressure and airway resistance (Rmin), as well as the additional resistance (δR) due to viscoelastic pressure dissipation and time-constant inequalities, were estimated by rapid airway occlusion during inflation. In seven out of nine patients, right-heart catheterization was performed and hemodynamic parameters were obtained at each value of TE. A significant decrease of intrinsic positive end-expiratory pressure (PEEPi), end-inspiratory static and mean (mPaw) airway pressures, end-expiratory lung volume above passive FRC (Vtrap), δR and venous admixture and a significant increase of peak airway pressure, Rmin, stroke volume index and mixed venous PO2 \(\left( {P\bar vO_2 } \right)\) were observed when\(\dot V_1 \) increased. At each\(\dot V_1 \), the addition of EIP significantly decreased iso-volume expiratory flows and\(P\bar vO_2 \) and increased Vtrap and mPaw.
Conclusions
We conclude that in mechanically ventilated patients with COPD, the pattern of lung inflation and TE alteration have a significant impact on respiratory system mechanics, gas exchange and hemodynamics. Addition of EIP in patients with COPD may be detrimental.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Pepe PE, Marini JJ (1982) Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction. Am Rev Respir Dis 126: 166–170
Georgopoulos D, Giannouli E, Patakas D (1993) Effect of extrinsic positive end-expiratory pressure on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation. Intensive Care Med 19: 197–203
Ranieri VM, Giulani R, Cinnella G, Pesce C, Brienza N, Ippoliti EL, Pomo V, Fiore T, Gottfried S, Brienza A (1993) Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 147: 5–13
Tantucci C, Eissa NT, Ranieri VM, Corbeil C, Milic-Emili (1992) Respiratory mechanics in ventilated patients. J Crit Care 4: 251–255
Marini JJ (1989) Should PEEP be used in airflow obstruction? (Editorial). Am Rev Respir Dis 140: 1–3
Fleury B, Murciano D, Talamo C, Aubier M, Pariente R, Milic-Emili J (1985) Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. Am Rev Respir Dis 132: 822–827
Rossi A, Gottfried SB, Higgs BD, Zocchi L, Grassino A, Milic-Emili J (1985) Respiratory mechanics in mechanically ventilated patients with respiratory failure. J Appl Physiol 58: 1849–1858
Williams T, Tuxen D, Scheinkestel C, Bowes G (1992) Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. Am Rev Respir Dis 146: 607–615
Tuxen DV, Lane S (1987) The effects of ventilatory pattern on hyperinflation, airways pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 136: 872–879
Connors AF, McCaffree RD Jr, Gray BA (1981) Effect of inspiratory flow rate on gas exchange during mechanical ventilation. Am Rev Respir Dis 124: 537–543
Marini JJ, Ravenscraft SA (1992) Mean airway pressure: Physiologic determinants and clinical importance. Part 1: Physiologic determinants and measurements. Crit Care Med 20: 1461–1472
Bates JHT, Rossi A, Milic-Emili J (1985) Analysis of the behaviour of the respiratory system with constant inspiratory flow. J Appl Physiol 58: 1840–1848
Kochi T, Okubo S, Zin WA, Milic-Emili J (1988) Flow and volume dependence of pulmonary mechanics in anesthetized cats. J Appl Physiol 64: 441–450
Shoemaker WC (1989) Shock state: pathophysiology, monitoring, outcome prediction and therapy. In: Shoemaker WC, Ayres, Grenvik, Holbrook, Thompson (eds) Textbook of critical care. Saunders, Philadelphia, pp 977–993
D'Angelo EF, Robatto FM, Calderini E, Tavola M, Bono D, Torri G, Milic-Emili J (1991) Pulmonary and chest wall mechanics in anesthetized paralyzed humans. J Appl Physiol 70: 2602–2610
Guerin C, Coussa ML, Eissa NT, Corbeil C, Chasse M, Braidy J, Matar N, Milic-Emili J (1993) Lung and chest wall mechanics in mechanically ventilated COPD patients. J Appl Physiol 74: 1570–1580
D'Angelo E, Prandi E, Milic-Emili J (1993) Dependence of maximal flow-volume curves on time course of preceding inspiration. J Appl Physiol 75: 1155–1159
Georgopoulos D, Gomez A, Mink S (1994) Factors determining lobar emptying during maximal and partial forced deflations in nonhomogeneous airway obstruction in dogs. Am J Respir Crit Care Med 149: 1241–1247
Broseghini C, Brandolese R, Poggi R, Polese G, Manzin E, Milic-Emili J, Rossi A (1988) Respiratory mechanics during the first day of mechanical ventilation in patients with pulmonary edema and chronic airway obstruction. Am Rev Respir Dis 138: 355–361
D'Angelo EF, Calderini E, Torri G, Robatto FM, Bono D, Milic-Emili J (1989) Respiratory mechanics in anesthetized paralysed humans: effects of flow, volume, and time. J Appl Physiol 67: 2556–2564
Pesenti A, Pelosi P, Rossi N, Virtuani A, Brazzi L, Rossi A (1991) The effects of positive end-expiratory pressure on respiratory resistance in patients with the adult respiratory distress syndrome and in normal anesthetized subjects. Am Rev Respir Dis 144: 101–107
Eissa NT, Ranieri VM, Corbeil C, Chasse M, Robatto FM, Braidy J, Milic-Emili J (1991) Analysis of behaviour of the respiratory system in ARDS patients: effects of flow, volume, and time. J Appl Physiol 70: 2719–2729
West JB, Wagner PD (1977) Pulmonary gas exchange. In: West JB (ed) Bioengineering aspects of the lung. Marcel Dekker, New York, pp 361–457
Marini JJ, Ravenscraft SA (1992) Mean airway pressure: physiologic determinants and clinical importance. 2. Clinical implications. 20: 1604–1616
Dhainault JF, Aouate P, Brunet FP (1989) Circulatory effect of positive end-expiratory pressure in patients with acute lung injury. In: Scharf SM, Cassidy SS (eds) Heart-lung interaction in health and disease. Marcel Dekker, New York, pp 809–838
Georgopoulos D, Anthonisen NR (1990) Oxygen therapy. Curr Pulmonol 11: 221–246
Carlile PV, Gray BA (1989) Effect of opposite changes in cardiac output and arterial PO2 on the relationship between mixed venous PO2 and oxygen transport. Am Rev Respir Dis 140: 891–898
Sykes MK, McNicol MW, Cambell EJM (1969) Respiratory failure in pulmonary disease. In: Respiratory failure. Davis, Philadelphia, pp 243–272
Webb AK, Bilton RH, Hanson G (1979) Severe bronchial asthma requiring ventilation. A review of 20 cases and advise on management. Postgrad Med J 55: 161–170
Fuleihan SF, Wilson RS, Pontoppidan H (1976) Effect of mechanical ventilation with end-inspiratory pause on blood-gas exchange. Anesth Analg 55: 122–130
Blanch PB, Jones M, Layon AJ, Camner N (1993) Pressure-preset ventilation. 2. Mechanics and safety. Chest 104: 904–912
Puddy A, Younes M (1992) Effect of inspiratory flow rate on respiratory output in normal subjects. Am Rev Respir Dis 146: 787–789
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Georgopoulos, D., Mitrouska, I., Markopoulou, K. et al. Effects of breathing patterns on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation. Intensive Care Med 21, 880–886 (1995). https://doi.org/10.1007/BF01712328
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF01712328