Abstract
Objective
The aims of the present study were two-fold: first, to confirm the effect of tracheal gas insufflation (TGI) throughout the respiratory cycle on alveolar ventilation at various catheter flows and constant total inspired VT as an adjunct to conventional volume cycled mechanical ventilation in patients with acute lung injury; second, to test the efficacy of TGI in the reduction of toal VT, peak and mean airway pressure while maintaining PaCO2 in its baseline value. The hemodynamic effect and the consequences on oxygenation as result of the reduction of VT, were also estimated.
Design
Prospective study of patients with acute lung injury requiring mechanical ventilation.Setting: 12 bedded, adult polyvalent intensive care unit in a teaching hospital.
Patients
7 paralyzed and sedated patients with acute respiratory failure were studied. All patients were clinically and hemodynamically stable without fluctuation of the body temperature. All patients were orally intubated with cuffed endotracheal tubes, and mechanically ventilated with a standard circuit of known compliance.
Interventions
Continuous flows (4 and 6 l/min) were delivered through a catheter positioned 1 cm above carina while tidal volume or PaCO2 were maintained constant at their baseline value.
Results
In this study a modest level of TGI significantly enhanced CO2 elimination in patients with acute respiratory failure. Improved ventilatory efficiency resulted from the functional reduction of dead space during TGI allowing the same PaCO2 to be maintained at the same frequency with lower tidal volume and lower airway pressure requirement. Tidal volume, peak and mean airway pressure decreased linearly with catheter flow, without significant changes in oxygenation, while PaCO2 remained stable.
Conclusion
The results of this study suggest that TGI may be an useful adjunct mode of mechanical ventilation that limits alveolar pressure and minute ventilation requirements.
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References
Marini J, Culver B (1989) Systemic gas embolism complicating mechanical ventilation in ARDS. Ann Intern Med 110:699
Petersen G, Baier H (1983) Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 11:67
Carlton D, Cummings J, Scheerer R, Poulain F, Bland R (1990) Lung overexpansion increases pulmonary microvascular protein permeability in young lambs. J Appl Physiol 69:577–583
Dreyfuss D, Basset G, Soler P, Saumon G (1985) Intermittent positive-pressure hyperventilation with high inflation pressures produces pulmonary microvascular injury in rats. Am Rev Respir Dis 132:880–884
Dreyfuss D, Soler P, Basset G, Saumon G (1988) High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 137:1159–1164
Kolobow T, Moretti M, Fumagalle R, Mascheroni D, Prato P, Chen V, Joris M (1987) Severe impairment on lung function induced by high peak airway pressure during mechanical ventilation. Am Rev Respir Dis 135:312
Parker K, Hernandez L, Longenecker G, Peevy K, Johnson W (1990) Lung edema caused by high peak inspiratory pressure in dogs. Am Rev Respir Dis 142:321–328
Peevy K, Hernandez L, Moise A, Parker J (1990) Barotrauma and microvascular injury in lung of non adult rabbits: effect of ventilation pattern. Crit Care Med 18:634
Tsuno K, Prato P, Kolobow T (1990) Acute lung injury from mechanical ventilation at moderately high airway pressure. J Appl Physiol 69:956
Dreyfuss D, Soler P, Saumon G (1989) Overinflation pulmonary edema is not related to large swings but to the level of lung distention. Am Rev Respir Dis 139 [Suppl]:A417
Hernandez L, Peevy K, Moise A, Parker J (1989) Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. J Appl Physiol 66:2364–2368
Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M (1987) Pressure-volume curve of total respiratory system in acute respiratory failure. Computer tomographic study. Am Rev Respir Dis 136:730–736
Mascheroni D, Kolobow T, Fumagalli R, Moretti M, Chen V, Buckhold D (1988) Acute respiratory failure following pharmacologically induced hyperventilation: an experimental study. Intensive Care Med 15:8–14
Sinard J, Bartlett R (1990) Extracorporeal life support in critical care medicine. J Crit Care 5:265–278
Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F, Iapichino G et al (1986) Low-frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 256:881–886
Hickling K (1990) Ventilatory management of ARDS: can it affect outcome? Intensive Care Med 16:219–226
Ravenscraft S, Burke W, Nahum A, Adams A, Nakos G, Marini J (1993) Tracheal gas insufflation augments CO2 clearance during mechanical ventilation. Am Rev Respir Dis 148:345–351
Stresemann E, Votteri B, Sattler F (1969) Washout of anatomical dead space for alveolar hypoventilation. Respiration 26:425–434
Nahum A, Ravenscraft S, Nakos G, Burke W, Adams A, Marini J (1992) Tracheal gas insufflation during pressure-control ventilation: effect of catheter position, diameter, and flow rate. Am Rev Respir Dis 146:1411–1418
Hurewitz A, Bergofsky E, Vomero E (1991) Airway insufflation: increasing flow rates progressively reduce dead space in respiratory failure. Am Rev Respir Dis 144:1229–1233
Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723
Ravenscraft S, McArthur C, Path M, Iber C (1991) Components of excess ventilation in patients initiated on mechanical ventilation. Crit Care Med 19:916–925
Enghoff H (1938) Volumen inefficax. Bemerkungen zur Frage des schädlichen Raumes. Uppsala Lakarefoeren Forh 44:191–218
Nahum A, Burke W, Ravenscraft S, Marcy T, Adams A, Crooke P, Marini J (1992) Lung mechanics and gas exchange during pressure control ventilation in dogs: augmentation of CO2 elimination by an intratracheal catheter. Am Rev Respir Dis 146:965–973
Watson J, Burwen D, Kamm R, Brown R, Slutsky A (1986) Effect of flow rate on blood gases during constant flow ventilation in dogs. Am Rev Respir Dis 133:626–629
Nahum A, Ravenscraft S, Nakos G, Burke W, Adams A, Marini J (1993) Effect of catheter flow direction on CO2 removal during tracheal gas insufflation in dogs. J Appl Physiol 75:1238–1246
Burke W, Nahum A, Ravenscraft S, Nakos G, Adams A, Marcy T, Marini J (1993) Modes of tracheal gas insufflation: comparison of continuous and phase specific gas injection in normal dogs. Am Rev Respir Dis 148:562–568
Marini J, Ravenscraft S (1992) Mean airway pressure: physiologic determinants and clinical importance. Part I: physiologic determinants and measurements. Crit Care Med 20:1461–1472
Nakos G, Adams A, Burke W, Nahum A, Ravenscraft S, Marini J (1992) Prediction of mean alveolar pressure from mean airway pressure at various points along the circuit in a mechanical model. Am Rev Respir Dis 145:A782
Dantzeker D, Lynch J, Weg J (1980) Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure. Chest 77:636–642
Kiiski R, Takala J, Kari A, Milic-Emili J (1992) Effect of the tidal volume on gas exchange and oxygen transport in the ARDS. Am Rev Respir Dis 146:1131–1135
Leatherman J, Lari R, Iber C, New A (1991) Tidal volume reduction in ARDS: effect on cardiac output and arterial oxygenation. Chest 99:1227–1231
Bruderman I, Alkalay I, Stein M, Frank H (1966) Tracheostomy for acute respiratory failure. Chest 50:393–402
Christpher K, Spofford B, Brannin P, Petty T (1986) Transtracheal oxygen therapy for refractory hypoxemia. JAMA 256:494–497
Heimlich H (1992) Respiratory rehabilition with transtracheal oxygen system. Ann Otol Rhinol Laryngol 91:643–647
Couser J, Make B (1989) Transtracheal oxygen decreases inspired minute ventilation. Am Rev Respir Dis 139:627–631
Slutsky A, Watson J, Leith D, Brown R (1985) Tracheal insufflation of O2 (TRIO) at low flow rates sustains life for several hours. Anesthesiology 63:278–286
Meltzer S, Auer J (1909) Continuous respiration without respiratory movements. J Exp Med 11:622–625
Meltzer S (1911) Intratracheal insufflation. JAMA 57:521–525
Bergofsky E, Hurewitz A (1989) Airway insufflation:physiologic effect on acute and chronic gas exchange in humans. Am Rev Respir Dis 140:885–890
Gilbert J, Larsson A, Smith R, Bunegin L (1991) Intermittent-flow expiratory ventilation (IFEV):delivery technique and principles of action-a preliminary communication. Biomed Instrum Technol 25:451–456
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Nakos, G., Zakinthinos, S., Kotanidou, A. et al. Tracheal gas insufflation reduces the tidal volume while PaCO2 is maintained constant. Intensive Care Med 20, 407–413 (1994). https://doi.org/10.1007/BF01710650
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DOI: https://doi.org/10.1007/BF01710650