Measurement Of End-expiratory Lung Volume Research Articles

Physiologic Effects of Reconnection to the Ventilator for 1 Hour Following a Successful Spontaneous Breathing Trial

Reconnection to the ventilator for 1 hour after a successful spontaneous breathing trial (SBT) may reduce reintubation rate as compared to direct extubation. However, the physiological mechanisms leading to this effect are unclear. Does reconnection to the ventilator for 1 hour reverse alveolar derecruitment induced by SBT, and is alveolar derecruitment more pronounced with a T-piece than with pressure-support ventilation (PSV)? Ancillary study of a randomized clinical trial comparing SBT performed with a T-piece or with PSV. Alveolar recruitment was assessed using measurement of end-expiratory lung volume (EELV). Out of 25 patients analyzed after successful SBT, 11 underwent SBT with a T-piece and 14 with PSV. At the end of the SBT, EELV decreased by -30% (95% confidence interval, -37% to -23%) compared with baseline before the SBT. This reduction was greater with a T-piece than with PSV: -43% (95% CI, -51% to -35%) vs. -20% (95% CI, -26% to -13%), p<0.001. After reconnection to the ventilator for 1 hour, EELV accounted for 96% (95% CI, 92% to 101%) of baseline EELV and did not significantly differ from before the SBT (p=0.104). After 10 minutes of reconnection to the ventilator, EELV wasted at the end of the SBT was completely recovered using PSV (p=0.574) whereas it remained lower than before the SBT using T-piece (p=0.010). Significant alveolar derecruitment was observed at the end of a SBT, and was markedly more pronounced with a T-piece than with PSV. Reconnection to the ventilator for 1 hour allowed complete recovery of alveolar derecruitment. NCT04227639.

Recruitment-to-inflation ratio assessed through sequential end-expiratory lung volume measurement in acute respiratory distress syndrome.

Positive end-expiratory pressure (PEEP) benefits in acute respiratory distress syndrome (ARDS) are driven by lung dynamic strain reduction: this depends on the variable extent of alveolar recruitment. The recruitment-to-inflation (R/I) ratio estimates recruitability across a 10-cmH2O PEEP range through a simplified maneuver. Whether recruitability is uniform or not across this range is unknown. The hypotheses of this study are that R/I represents an accurate estimate of PEEP-induced changes in dynamic strain, but may show a non-uniform behaviour across the conventionally tested PEEP range (15-5 cmH2O). Twenty patients with moderate-to-severe COVID-19 ARDS underwent a decremental PEEP trial (PEEP 15-13-10-8-5 cmH2O). Respiratory mechanics and end-expiratory lung volume by nitrogen dilution were measured the end of each step. Gas exchange, recruited volume, R/I, changes in dynamic, static and total strain were computed between 15 and 5 cmH2O (global R/I) and within narrower PEEP ranges (granular R/I). Between 15 and 5 cmH2O, median [Interquartile range] global R/I was 1.27 [0.40-1.69] and displayed a linear correlation with PEEP-induced dynamic strain reduction (r=-0.94, p<0.001). Intra-individual R/I variability within the narrower ranges was high (85% [70-109]). The relationship between granular R/I and PEEP was mathematically described by a non-linear, quadratic equation (r 2=0.96). Granular R/I across the narrower PEEP ranges had itself a linear correlation with PEEP-induced reduction in dynamic strain (r=-0.89, p<0.001). Both global and granular R/I well estimate PEEP-induced changes in lung dynamic strain. However, the effect of 10-cmH2O of PEEP on lung strain may be non-uniform. Granular R/I assessment within narrower PEEP ranges guided by end-expiratory lung volume measurement may aid more precise PEEP selection, especially when R/I obtained with the simplified maneuver between PEEP 15 and 5 cmH2O yields intermediate values, that are difficult to interpret for a proper choice between a high vs. low PEEP strategy.

Thoracic electrical impedance tomography: an adaptive monitor for dynamic organs

Electrical impedance tomography (EIT) is increasingly used in intensive care patients to monitor pulmonary and cardiac function non-invasively at the bedside. Impedance variations measured by EIT due to a change in thoracic air content represent the largest and most studied signal, allowing the measurement of end-expiratory lung volume (EELV), global and regional ventilation and spatial and temporal heterogeneity of ventilation distribution. This technique gives a dynamic, repeatable, global and regional description of the respiratory system mechanics, providing at the same time a dynamic picture of lung function. A smaller but detectable change in electrical impedance is due to the increase/decrease of blood content into lung vascular tree during the cardiac cycle. This signal is used to measure stroke volume and global and regional lung perfusion. The integration of the ventilation and perfusion components of the EIT signal can be used to measure ventilation-perfusion matching. The aim of this review is to describe the current clinical applications of EIT, providing a guide to the most relevant physiologic variables derived from EIT and their clinical meaning. We will focus on respiratory and cardiac-related variables and their application in both the anesthetized and awake patients. A special attention will be given to two greatly expanding fields of use: pediatric patients and the perioperative (adult and pediatric) setting. Finally, we will describe potential future applications which we expect will soon become a reality, with the potential to change our everyday practice in the intensive care unit and the operating theatre.

Endexpiratory lung volume measurement correlates with the ventilation/perfusion mismatch in lung injured pigs

BackgroundIn acute respiratory respiratory distress syndrome (ARDS) a sustained mismatch of alveolar ventilation and perfusion (VA/Q) impairs the pulmonary gas exchange. Measurement of endexpiratory lung volume (EELV) by multiple breath-nitrogen washout/washin is a non-invasive, bedside technology to assess pulmonary function in mechanically ventilated patients. The present study examines the association between EELV changes and VA/Q distribution and the possibility to predict VA/Q normalization by means of EELV in a porcine model.MethodsAfter approval of the state and institutional animal care committee 12 anesthetized pigs were randomized to ARDS either by bronchoalveolar lavage (n = 6) or oleic acid injection (n = 6). EELV, VA/Q ratios by multiple inert gas elimination and ventilation distribution by electrical impedance tomography were assessed at healthy state and at five different positive endexpiratory pressure (PEEP) steps in ARDS (0, 20, 15, 10, 5 cmH2O; each maintained for 30 min).ResultsVA/Q, EELV and tidal volume distribution all displayed the PEEP-induced recruitment in ARDS. We found a close correlation between VA/Q < 0.1 (representing shunt and low VA/Q units) and changes in EELV (spearman correlation coefficient −0.79). Logistic regression reveals the potential to predict VA/Q normalization (VA/Q < 0.1 less than 5%) from changes in EELV with an area under the curve of 0.89 with a 95%-CI of 0.81–0.96 in the receiver operating characteristic. Different lung injury models and recruitment characteristics did not influence these findings.ConclusionIn a porcine ARDS model EELV measurement depicts PEEP-induced lung recruitment and is strongly associated with normalization of the VA/Q distribution in a model-independent fashion. Determination of EELV could be an intriguing addition in the context of lung protection strategies.

End-Expiratory Lung Volume in Patients with Acute Respiratory Distress Syndrome: A Time Course Analysis.

Lung injury can be caused by ventilation and non-physiological lung stress (transpulmonary pressure) and strain [inflated volume over functional residual capacity ratio (FRC)]. FRC is severely decreased in patients with acute respiratory distress syndrome (ARDS). End-expiratory lung volume (EELV) is FRC plus lung volume increased by the applied positive end-expiratory pressure (PEEP). Measurement using the modified nitrogen multiple breath washout technique may help titrating PEEP during ARDS and allow determining dynamic lung strain (tidal volume over EELV) in patients ventilated with PEEP. In this observational study, we measured EELV for up to seven consecutive days in patients with ARDS at different PEEP levels. Thirty sedated patients with ARDS (10 mild, 14 moderate, 6 severe) underwent decremental PEEP testing (20, 15, 10, 5cm H2O) for up to 7days after inclusion. At all PEEP levels examined, over a period of 7days the measured absolute EELVs showed no significant change over time [PEEP 20cm H2O 2464ml at day 1 vs. 2144ml at day 7 (p=0.78), PEEP 15cm H2O 2226ml vs. 1990ml (p=0.36), PEEP 10 1835ml vs. 1858ml (p=0.76) and PEEP 5cm H2O 1487ml vs. 1612ml (p=0.37)]. In relation to the predicted body weight (pbw), no significant change in EELV/kg pbw over time could be detected either at any PEEP level or over time [PEEP 20 36ml/kg pbw at day 1 vs. 33ml/kg pbw at day 7 (p=0.66); PEEP 15 33 vs. 29ml/kg pbw (p=0.32); PEEP 10 27 vs. 27ml/kg pbw (p=0.70) and PEEP 5 22 vs. 24ml/kg pbw (p=0.70)]. Oxygenation significantly improved over time from PaO2/FiO2 of 169mmHg at day 1 to 199mmHg at day 7 (p<0.01). EELV did not change significantly for up to 7days in patients with ARDS. By contrast, PaO2/FiO2 improved significantly. Bedside measurement of EELV may be a novel approach to individualise lung-protective ventilation on the basis of calculation of dynamic strain as the ratio of VT to EELV.

Lung stress and strain calculations in mechanically ventilated patients in the intensive care unit.

BackgroundStress and strain are parameters to describe respiratory mechanics during mechanical ventilation. Calculations of stress require invasive and difficult to perform esophageal pressure measurements. The hypothesis of the present study was: Can lung stress be reliably calculated based on non‐invasive lung volume measurements, during a decremental Positive end‐expiratory pressure (PEEP) trial in mechanically ventilated patients with different diseases?MethodsData of 26 pressure‐controlled ventilated patients admitted to the ICU with different lung conditions were retrospectively analyzed: 11 coronary artery bypass graft (CABG), 9 neurology, and 6 lung disorders. During a decremental PEEP trial (from 15 to 0 cmH2O in three steps) end‐expiratory lung volume (EELV) measurements were performed at each PEEP step, without interruption of mechanical ventilation. Strain, specific elastance, and stress were calculated for each PEEP level. Elastance was calculated as delta PEEP divided by delta PEEP volume, whereas specific elastance is elastance times the FRC. Stress was calculated as specific elastance times the strain. Global strain was divided into dynamic (tidal volume) and static (PEEP) strain.ResultsStrain calculations based on FRC showed mainly changes in static component, whereas calculations based on EELV showed changes in both the static and dynamic component of strain. Stress calculated from EELV measurements was 24.0 ± 2.7 and 13.1 ± 3.8 cmH2O in the lung disorder group at 15 and 5 cmH2O PEEP. For the normal lungs, the stress values were 19.2 ± 3.2 and 10.9 ± 3.3 cmH2O, respectively. These values are comparable to earlier publications. Specific elastance calculations were comparable in patients with neurologic and lung disorders, and lower in the CABG group due to recruitment in this latter group.ConclusionStress and strain can reliably be calculated at the bedside based on non‐invasive EELV measurements during a decremental PEEP trial in patients with different diseases.

Head-of-bed elevation improves end-expiratory lung volumes in mechanically ventilated subjects: a prospective observational study.

Head-of-bed elevation (HOBE) has been shown to assist in reducing respiratory complications associated with mechanical ventilation; however, there is minimal research describing changes in end-expiratory lung volume. This study aims to investigate changes in end-expiratory lung volume in a supine position and 2 levels of HOBE. Twenty postoperative cardiac surgery subjects were examined using electrical impedance tomography. End-expiratory lung impedance (EELI) was recorded as a surrogate measurement of end-expiratory lung volume in a supine position and at 20° and then 30°. Significant increases in end-expiratory lung volume were seen at both 20° and 30° HOBE in all lung regions, except the anterior, with the largest changes from baseline (supine) seen at 30°. From baseline to 30° HOBE, global EELI increased by 1,327 impedance units (95% CI 1,080-1,573, P < .001). EELI increased by 1,007 units (95% CI 880-1,134, P < .001) in the left lung region and by 320 impedance units (95% CI 188-451, P < .001) in the right lung. Posterior increases of 1,544 impedance units (95% CI 1,405-1,682, P < .001) were also seen. EELI decreased anteriorly, with the largest decreases occurring at 30° (-335 impedance units, 95% CI -486 to -183, P < .001). HOBE significantly increases global and regional end-expiratory lung volume; therefore, unless contraindicated, all mechanically ventilated patients should be positioned with HOBE.

Assessment of ventilation inhomogeneity during mechanical ventilation using a rapid-response oxygen sensor-based oxygen washout method.

PurposeVentilatory inhomogeneity indexes in critically ill mechanically ventilated patients could be of importance to optimize ventilator settings in order to reduce additional lung injury. The present study compared six inhomogeneity indexes calculated from the oxygen washout curves provided by the rapid oxygen sensor of the LUFU end-expiratory lung volume measurement system.MethodsInhomogeneity was tested in a porcine model before and after induction of acute lung injury (ALI) at four different levels of positive end-expiratory pressure (PEEP; 15, 10, 5 and 0 cm H2O). The following indexes were assessed: lung clearance index (LCI), mixing ratio, Becklake index, multiple breath alveolar mixing inefficiency, moment ratio and pulmonary clearance delay.ResultsLCI, mixing ratio, Becklake index and moment ratio were comparable with previous reported values and showed acceptable variation coefficients at baseline with and without ALI. Moment ratio had the highest precision, as calculated by the variation coefficients. LCI, Becklake index and moment ratio showed comparable increases in inhomogeneity during decremental PEEP steps before and after ALI.ConclusionsThe advantage of the method we introduce is the combined measurement of end-expiratory lung volume (EELV) and inhomogeneity of lung ventilation with the LUFU fast-response medical-grade oxygen sensor, without the need for external tracer gases. This can be combined with conventional breathing systems. The moment ratio and LCI index appeared to be the most favourable for integration with oxygen washout curves as judged by high precision and agreement with previous reported findings. Studies are under way to evaluate the indexes in critically ill patients.

Effectiveness of end-expiratory lung volume measurements during the lung recruitment maneuver for patients with atelectasis

PurposeThe aim of this study was to determine whether the relative change in the end-expiratory lung volume (EELV) obtained by the recruitment maneuver (RM) can serve as an indicator of the change in the P/F ratio. Materials and MethodsThe effects of the intermittent stepwise increases in the RM (peak inspiratory pressure, 45, 50, and 55 cm H2O) were compared in 21 patients with atelectasis under mechanical ventilation. The EELV, the ratio of arterial oxygen concentration to the fraction of inspired oxygen P/F ratio, and relative change rate (Δ) in these parameters were evaluated after each RM. ResultsA greater improvement in the EELV (1157 ± 344 mL vs 1469 ± 396 mL) and P/F ratio (250 ± 99 vs 320 ± 92) was observed after the RM. The ΔEELV was correlated with the ΔP/F ratio (ρ = 0.73, P < .01) and was identified as an accurate predictor of the improvement of the ΔP/F ratio by the receiver operating characteristic curve (the area under the curve, 0.93; P < .01). ConclusionsThese results suggest that the ΔEELV obtained by intermittent stepwise RM can serve as an indicator of the change in the P/F ratio.

The Effect of Alveolar Dead Space on the Measurement of End-Expiratory Lung Volume by Modified Nitrogen Wash-Out/Wash-In in Lavage-Induced Lung Injury

The accuracy of end-expiratory lung volume measurement by the modified nitrogen wash-out/wash-in method (EELV-N(2)) depends on the precise determination of carbon dioxide elimination (V(CO(2))), which is affected by alveolar dead space (V(D-alv)). The purpose of this study was to investigate the influence of V(D-alv) on EELV-N(2). Six piglets with lavage-induced acute lung injury were mechanically ventilated in a decremental PEEP trial that was reduced from 20 to 4 cm H(2)O in steps of 4 cm H(2)O every 10 min. EELV was measured by the modified EELV-N(2) method and computed tomography scan (EELV-CT), volumetric capnography, blood gas measurements, and hemodynamic data were recorded at each PEEP level. The data were divided into higher and lower PEEP groups. During the decremental PEEP trial, EELV-N(2) exhibited a high correlation (r(2) = 0.86, P < .001) with EELV-CT, with a bias of -48.6 ± 150.7 mL (1 ± 18%). In the higher PEEP group, EELV-N(2) was not correlated with EELV-CT, with a bias of -168.1 ± 171.5 mL (-14 ± 14%). However, in the lower PEEP group, EELV-N(2) exhibited a high correlation (r(2) = 0.86, P < .001) with EELV-CT, with a bias of 11.2 ± 97.2 mL (6 ± 17%). The measurement bias was negatively correlated with V(D-alv) (r(2) = 0.44, P = .04) and V(CO(2)) (r(2) = 0.47, P = .03) in the higher PEEP group. In this surfactant-depleted model, EELV measurement by the modified EELV-N(2) method reveals a systematic underestimation at high PEEP levels that is partly due to an increase in V(D-alv).

PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment

Lung volumes, especially functional residual capacity (FRC), are decreased in acute respiratory distress syndrome (ARDS). Positive end-expiratory pressure (PEEP) contributes to increased end-expiratory lung volume (EELV) and to improved oxygenation, but differentiating recruitment of previously nonaerated lung units from distension of previously open lung units remains difficult. This study evaluated simple methods derived from bedside EELV measurements to assess PEEP-induced lung recruitment while monitoring strain. Prospective multicenter study in 30 mechanically ventilated patients with ARDS in five university hospital ICUs. Two PEEP levels were studied, each for 45min, and EELV (nitrogen washout/washin technique) was measured at both levels, with the difference (Δ) reflecting PEEP-induced lung volume changes. Alveolar recruitment was measured using pressure-volume (PV) curves. High and low recruiters were separated based on median recruitment at high PEEP. Minimum predicted increase in lung volume computed as the product of ΔPEEP by static compliance was subtracted from ΔEELV as an independent estimate of recruitment. Estimated and measured recruitments were compared. Strain induced by PEEP was also calculated from the same measurements. FRC was 31±11% of predicted. Median [25th-75th percentiles] PEEP-induced recruitment was 272 [187-355] mL. Estimated recruitment correlated with recruited volume measured on PV curves (ρ=0.68), with a slope close to identity. The ΔEELV/FRC ratio differentiated high from low recruiters (110 [76-135] vs. 55 [23-70]%, p=0.001). Strain increase due to PEEP was larger in high recruiters (p=0.002). PEEP-induced recruitment and strain can be assessed at the bedside using EELV measurement. We describe two bedside methods for predicting low or high alveolar recruitment during ARDS.

Prolonged moderate pressure recruitment manoeuvre results in lower optimal positive end-expiratory pressure and plateau pressure

In acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), recruitment manoeuvres (RMs) are used frequently. In pigs with induced ALI, superior effects have been found using a slow moderate-pressure recruitment manoeuvre (SLRM) compared with a vital capacity recruitment manoeuvre (VICM). We hypothesized that the positive recruitment effects of SLRM could also be achieved in ALI/ARDS patients. Our primary research question was whether the same compliance could be obtained using lower RM pressure and subsequent positive end-expiratory pressure (PEEP). Secondly, optimal PEEP levels following the RMs were compared, and the use of volume-dependent compliance (VDC) to identify successful lung recruitment and optimal PEEP was evaluated. We performed a prospective randomised cross-over study where 16 ventilated patients with early ALI/ARDS each were subjected to the two RMs, followed by decremental PEEP titration. Volume-dependent initial, middle and final compliance (C(ini) , C(mid) and C(fin) ) were determined. Electric impedance tomography and end-expiratory lung volume measurements were used to follow lung volume changes. The maximum response in compliance, PaO₂/FIO₂, venous admixture and C(ini) /C(fin) after recruitment, during decremental PEEP, was at significantly lower PEEP and plateau pressure after SLRM than VICM. Fewer patients responded in gas exchange after the SLRM, which was not the case for lung mechanics. The response in C(ini) was more pronounced than in conventional compliance. The same compliance increase is achieved with SLRM as with VICM, and lower PEEP can be used, with correspondingly lower plateau pressures. VDC seems promising to identify successful recruitment and optimal PEEP.

Accuracy and precision of end-expiratory lung-volume measurements by automated nitrogen washout/washin technique in patients with acute respiratory distress syndrome

IntroductionEnd-expiratory lung volume (EELV) is decreased in acute respiratory distress syndrome (ARDS), and bedside EELV measurement may help to set positive end-expiratory pressure (PEEP). Nitrogen washout/washin for EELV measurement is available at the bedside, but assessments of accuracy and precision in real-life conditions are scant. Our purpose was to (a) assess EELV measurement precision in ARDS patients at two PEEP levels (three pairs of measurements), and (b) compare the changes (Δ) induced by PEEP for total EELV with the PEEP-induced changes in lung volume above functional residual capacity measured with passive spirometry (ΔPEEP-volume). The minimal predicted increase in lung volume was calculated from compliance at low PEEP and ΔPEEP to ensure the validity of lung-volume changes.MethodsThirty-four patients with ARDS were prospectively included in five university-hospital intensive care units. ΔEELV and ΔPEEP volumes were compared between 6 and 15 cm H2O of PEEP.ResultsAfter exclusion of three patients, variability of the nitrogen technique was less than 4%, and the largest difference between measurements was 81 ± 64 ml. ΔEELV and ΔPEEP-volume were only weakly correlated (r2 = 0.47); 95% confidence interval limits, -414 to 608 ml). In four patients with the highest PEEP (≥ 16 cm H2O), ΔEELV was lower than the minimal predicted increase in lung volume, suggesting flawed measurements, possibly due to leaks. Excluding those from the analysis markedly strengthened the correlation between ΔEELV and ΔPEEP volume (r2 = 0.80).ConclusionsIn most patients, the EELV technique has good reproducibility and accuracy, even at high PEEP. At high pressures, its accuracy may be limited in case of leaks. The minimal predicted increase in lung volume may help to check for accuracy.

Measurement of end-expiratory lung volume in intubated children without interruption of mechanical ventilation

PurposeMonitoring end-expiratory lung volume (EELV) is a valuable tool to optimize respiratory settings that could be of particular importance in mechanically ventilated pediatric patients. We evaluated the feasibility and precision of an intensive care unit (ICU) ventilator with an in-built nitrogen washout/washin technique in mechanically ventilated pediatric patients.MethodsDuplicate EELV measurements were performed in 30 patients between 5 kg and 43 kg after cardiac surgery (age, median + range: 26, 3–141 months). All measurements were taken during pressure-controlled ventilation at 0 cm H2O of positive end-expiratory pressure (PEEP).ResultsLinear regression between duplicate measurements was excellent (R2 = 0.99). Also, there was good agreement between duplicate measurements, bias ± SD: −0.3% (−1.5 mL) ± 5.9% (19.2 mL). Mean EELV ± SD was 19.6 ± 5.1 mL/kg at 0 cm H2O PEEP. EELV correlated with age (p < 0.001, r = 0.92, R2 = 0.78), body weight (p < 0.001, r = 0.91, R2 = 0.82) and height (p < 0.001, r = 0.94, R2 = 0.75).ConclusionThis ICU ventilator with an in-built nitrogen washout/washin EELV technique can measure EELV with precision, and can easily be used for mechanically ventilated pediatric patients.

Lung volume calculated from electrical impedance tomography in ICU patients at different PEEP levels

PurposeTo study and compare the relationship between end-expiratory lung volume (EELV) and changes in end-expiratory lung impedance (EELI) measured with electrical impedance tomography (EIT) at the basal part of the lung at different PEEP levels in a mixed ICU population.MethodsEnd-expiratory lung volume, EELI and tidal impedance variation were determined at four PEEP levels (15–10–5–0 cm H2O) in 25 ventilated ICU patients. The tidal impedance variation and tidal volume at 5 cm H2O PEEP were used to calculate change in impedance per ml; this ratio was then used to calculate change in lung volume from change in EELI. To evaluate repeatability, EELV was measured in quadruplicate in five additional patients.ResultsThere was a significant but relatively low correlation (r = 0.79; R2 = 0.62) and moderate agreement (bias 194 ml, SD 323 ml) between ∆EELV and change in lung volume calculated from the ∆EELI. The ratio of tidal impedance variation and tidal volume differed between patients and also varied at different PEEP levels. Good agreement was found between repeated EELV measurements and washin/washout of a simulated nitrogen washout technique.ConclusionDuring a PEEP trial, the assumption of a linear relationship between change in global tidal impedance and tidal volume cannot be used to calculate EELV when impedance is measured at only one thoracic level just above the diaphragm.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-009-1512-6) contains supplementary material, which is available to authorized users.

Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea

Many patients with obstructive sleep apnea (OSA) have spontaneous periods of stable flow limited breathing during sleep without respiratory events or arousals. In addition, OSA is often more severe during REM than NREM and more severe during stage 2 than slow wave sleep (SWS). The physiological mechanisms for these observations are unknown. Thus we aimed to determine whether the activity of two upper airway dilator muscles (genioglossus and tensor palatini) or end-expiratory lung volume (EELV) differ between (1) spontaneously occurring stable and cyclical breathing and (2) different sleep stages in OSA. Physiologic observation. Sleep physiology laboratory. 15 OSA patients with documented periods of spontaneous stable breathing. Subjects were instrumented with intramuscular electrodes for genioglossus and tensor palatini electromyograms (EMGGG and EMGTP), chest and abdominal magnetometers (EELV measurement), an epiglottic pressure catheter (respiratory effort), and a mask and pneumotachograph (airflow/ventilation). Patients slept supine overnight without CPAP. Peak and Tonic EMGGG were significantly lower during cyclical (85.4 ± 2.7 and 94.6 ± 4.7 % total activity) than stable breathing (109.4 ± 0.4 and 103 ± 0.8 % total activity, respectively). During respiratory events in REM, tonic EMGGG activity was lower than during respiratory events in stage 2 (71.9 ± 5.1 and 119.6 ± 5.6 % total activity). EMGGG did not differ between stable stage 2 and stable SWS (98.9 ± 3.2 versus 109.7 ± 4.4 % total activity), nor did EMGTP or EELV differ in any breathing condition/sleep stage. Increased genioglossus muscle tone is associated with spontaneous periods of stable flow limited breathing in the OSA subjects studied. Reductions in genioglossus activity during REM may explain the higher severity of OSA in that stage. Increased lung volume and tensor palatini activity do not appear to be major mechanisms enabling spontaneous stable flow limited breathing periods.

Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea

Many patients with obstructive sleep apnea (OSA) have spontaneous periods of stable flow limited breathing during sleep without respiratory events or arousals. In addition, OSA is often more severe during REM than NREM and more severe during stage 2 than slow wave sleep (SWS). The physiological mechanisms for these observations are unknown. Thus we aimed to determine whether the activity of two upper airway dilator muscles (genioglossus and tensor palatini) or end-expiratory lung volume (EELV) differ between (1) spontaneously occurring stable and cyclical breathing and (2) different sleep stages in OSA. Physiologic observation. Sleep physiology laboratory. 15 OSA patients with documented periods of spontaneous stable breathing. Subjects were instrumented with intramuscular electrodes for genioglossus and tensor palatini electromyograms (EMG(GG) and EMG(TP)), chest and abdominal magnetometers (EELV measurement), an epiglottic pressure catheter (respiratory effort), and a mask and pneumotachograph (airflow/ventilation). Patients slept supine overnight without CPAP. Peak and Tonic EMG(GG) were significantly lower during cyclical (85.4 +/- 2.7 and 94.6 +/- 4.7 % total activity) than stable breathing (109.4 +/- 0.4 and 103 +/- 0.8% total activity, respectively). During respiratory events in REM, tonic EMG(GG) activity was lower than during respiratory events in stage 2 (71.9 +/- 5.1 and 119.6 +/- 5.6% total activity). EMG(GG) did not differ between stable stage 2 and stable SWS (98.9 +/- 3.2 versus 109.7 +/- 4.4% total activity), nor did EMG(TP) or EELV differ in any breathing condition/sleep stage. Increased genioglossus muscle tone is associated with spontaneous periods of stable flow limited breathing in the OSA subjects studied. Reductions in genioglossus activity during REM may explain the higher severity of OSA in that stage. Increased lung volume and tensor palatini activity do not appear to be major mechanisms enabling spontaneous stable flow limited breathing periods.

Measurement of end-expiratory lung volume by oxygen washin–washout in controlled and assisted mechanically ventilated patients

Assessing limits of agreement with helium dilution and repeatability of a new system (lung funcution, LUFU) that measures end-expiratory lung volume (EELV) in mechanically ventilated patients using the O(2) washin (EELV(Win)) and washout (EELV(Wout)) technique. LUFU consists of an Evita 4 ventilator, a side-stream oxygen analyzer, and a dedicated PC software. Prospective human study in a general ICU of a University hospital. Thirty-six mechanically ventilated patients. We obtained 36 couples of both EELV(Win) and EELV(Wout) measurements in each patient (5 with healthy lungs, 9 with ALI, 22 with ARDS). Measurements were obtained with patients ventilated either by assisted (ASB, 16 measurements) or controlled (CMV, 20 measurements) ventilation. In 19 of 20 cases in CMV, we obtained helium dilution measurements (EELV(He)). Bias for agreement with EELV(He) was -16 +/- 156 and 8 +/- 161 ml, respectively, for EELV(Win) and EELV(Wout). Bias for agreement between EELV(Win) and EELV(Wout) was 28 +/- 78 and 23 +/- 168 ml, respectively, for CMV and ASB. During CMV bias for repeatability were 8 +/- 92 and 23 +/- 165 ml, respectively, for EELV(Win) and EELV(Wout). During ASB bias for repeatability were 32 +/- 160 and -15 +/- 147 ml, respectively, for EELV(Win) and EELV(Wout). The LUFU method showed good agreement with helium, and good repeatability during partial and controlled mechanical ventilation. The technique is simple and safe.

Lung volume in mechanically ventilated patients: measurement by simplified helium dilution compared to quantitative CT scan

We describe a simplified helium dilution technique to measure end-expiratory lung volume (EELV) in mechanically ventilated patients. We assessed both its accuracy in comparison with quantitative computerized tomography (CT) and its precision. Prospective human study. Twenty-one mechanically ventilated ALI/ARDS patients. All patients underwent a spiral CT scan of the thorax during an end-expiratory occlusion. From the CT scan we computed the gas volume of the lungs (EELVCT). Within a few minutes, a rebreathing bag, containing a known amount of helium, was connected to the endotracheal tube, and the gas mixture diluted in the patient's lungs by delivering at least ten large tidal volumes. From the final helium concentration, EELV could be calculated by a standard formula (EELVHe). The results obtained by the two techniques showed a good correlation (EELVHe=208+0.858xEELV(CT), r=0.941; P<0.001). Bias between the two techniques was 32.5+/-202.8 ml (95% limits of agreement were -373 ml and +438 ml), with a mean absolute difference of 15%. The amount of pathological tissue did not affect the difference between the two techniques, while the amount of hyperinflated tissue did. Bias between two repeated helium EELV measurements was -24+/-83 ml (95% limits of agreement were -191 ml and +141 ml), with a mean absolute difference of 6.3%. The proposed helium dilution technique is simple and reproducible. The negligible bias and the acceptable level of agreement support its use as a practical alternative to CT for measuring EELV in mechanically ventilated ARDS patients.

Adaptation of the inert gas FRC technique for use in heavy exercise

We automated the inert gas rebreathe technique for measurement of end-expiratory lung volume (EELV) during heavy exercise. We also assessed the use of two gas tracers (He and N2) vs. a single gas tracer (He) for measurement of this lung volume and compared the two-tracer EELV to changes in the inspiratory capacity (defined with transpulmonary pressure) and shifts in the end-expiratory pressure from rest through heavy exercise. A computer program switched a pneumatic valve when flow crossed zero at end expiration and defined points in the He and N2 traces for calculation of EELV. An inherent delay of the rebreathing valve (50 ms) caused virtually no error at rest and during light exercise and an error of 74 +/- 9 ml in the EELV at peak inspiratory flow rates of 4 l/s. The measurement of EELV by the two gas tracers was closely correlated to the single-gas tracer measurement (r = 0.97) but was consistently higher (120 +/- 10 ml) than when He was used alone. This difference was accentuated with increased work rates (2-5% error in the EELV, rest to heavy exercise) and as rebreathe time increased (2-7% error in the EELV with rebreathe times of 5-20 s for all work loads combined). The double-gas tracer measurement of EELV agreed quite well with the thoracic gas volume at rest (P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)