Endotracheal tube resistance and inertance in a model of mechanical ventilation of newborns and small infants—the impact of ventilator settings on tracheal pressure swings

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Resistive properties of endotracheal tubes (ETTs) are particularly relevant in newborns and small infants who are generally ventilated through ETTs with a small inner diameter. The ventilation rate is also high and the inspiratory time (ti) is short. These conditions effectuate high airway flows with excessive flow acceleration, so airway resistance and inertance play an important role. We carried out a model study to investigate the impact of varying ETT size, lung compliance and ventilator settings, such as peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP) and inspiratory time (ti) on the pressure–flow characteristics with respect to the resistive and inertive properties of the ETT. Pressure at the Y piece was compared to direct measurement of intratracheal pressure (Ptrach) at the tip of the ETT, and pressure drop (ΔPETT) was calculated. Applying published tube coefficients (Rohrer's constants and inertance), Ptrach was calculated from ventilator readings and compared to measured Ptrach using the root-mean-square error. The most relevant for ΔPETT was the ETT size, followed by (in descending order) PIP, compliance, ti and PEEP, with gas flow velocity being the principle in common for all these parameters. Depending on the ventilator settings ΔPETT exceeded 8 mbar in the smallest 2.0 mm ETT. Consideration of inertance as an additional effect in this setting yielded a better agreement of calculated versus measured Ptrach than Rohrer's constants alone. We speculate that exact tracheal pressure tracings calculated from ventilator readings by applying Rohrer's equation and the inertance determination to small size ETTs would be helpful. As an integral part of ventilator software this would (1) allow an estimate of work of breathing and implementation of an automatic tube compensation, and (2) be important for gentle ventilation in respiratory care, especially of small infants, since it enables the physician to estimate consequences of altered ventilator settings at the tracheal level.