Inspiratory Time Research Articles

The Impact of Pneumoperitoneum on Mean Expiratory Flow Rate: Observational Insights from Patients with Healthy Lungs.

Surgical pneumoperitoneum (PP) significantly impacts volume-controlled ventilation, characterized by reduced respiratory compliance, elevated peak inspiratory pressure, and an accelerated expiratory phase due to an earlier onset of the airway pressure gradient. We hypothesized that this would shorten expiratory time, potentially increasing expiratory flow rate compared to pneumoperitoneum conditions. Calculations were performed to establish correlations between respiratory parameters and the mean increase in expiratory flow rate relative to baseline. Mechanical ventilation parameters were recorded for 67 patients both pre- and post-PP. Ventilator settings were standardized with a tidal volume of 6 mL/kg, a respiratory rate of 12 breaths per minute, a PEEP of 3 cmH2O, an inspiratory time of 2 s, and an inspiratory-to-expiratory ratio of 1:1.5 (I:E). The application of PP increased both peak inspiratory pressure and mean expiratory flow rate by 28% compared to baseline levels. The elevated intra-abdominal pressure of 20 cmH2O resulted in a 34% reduction in dynamic chest compliance, a 50% increase in elastance, and a 20% increase in airway resistance. The mean expiratory flow rate increments relative to baseline showed a significant negative correlation with elastance (p = 0.0119) and a positive correlation with dynamic compliance (p = 0.0028) and resistance (p = 0.0240). A PP of 20 cmH2O resulted in an increase in the mean expiratory flow rate in the conventional I:E ratio in the volume-ventilated mode. PP reduces lung and chest wall compliance by elevating the diaphragm, compressing the thoracic cavity, and increasing airway pressures. Consequently, the lungs and chest wall stiffen, requiring greater ventilatory effort and accelerating expiratory flow due to increased airway resistance and altered pulmonary mechanics. Prolonging the inspiratory phase through I:E ratio adjustment helps maintain peak inspiratory pressures closer to baseline levels, and this method enhances the safety and efficacy of mechanical ventilation in maintaining optimal respiratory function during laparoscopic surgery.

Probing kaon meson condensations through gravitational waves during neutron star inspiral phases

Gravitational waves from binary neutron star merger events have shown unparalleled advantages in deciphering the stellar internal structure, yet it remains underexplored to seek clues about kaon meson condensations inside massive neutron stars through these events. To address this gap, this study examines the binary star inspiral processes with kaon meson condensations, employing various kaon meson potential wells to probe unique imprints in the inspiral gravitational waves. Our analysis reveals that the inspiral process of kaon meson condensation binary stars exhibits lower gravitational wave frequencies and shorter retarded times compared to traditional neutron stars. Furthermore, a deeper kaon meson potential well in these systems further shortens the inspiral duration time, resulting in distinctive gravitational waveforms and notable orbital phase deviations. These findings underscore the pivotal role of kaon meson condensations in modulating the inspiral gravitational waves, suggesting the inspiral gravitational waves could serve as a powerful tool for probing potential signals of kaon mesons within neutron stars.

Intermittent sigh breaths during high-frequency oscillatory ventilation in preterm infants: a randomised crossover study

ObjectiveTo determine if combining high-frequency oscillatory ventilation (HFOV) with additional sigh breaths would improve end-expiratory lung volume (EELV) and oxygenation in preterm infants.DesignProspective interventional crossover study.SettingNeonatal intensive care unit.PatientsVentilated preterm...

Role of the Kölliker-Fuse/parabrachial complex in the generation of postinspiratory vagal and sympathetic nerve activities and their recruitment by hypoxemic stimuli in the rat.

In the rat, the activity of laryngeal adductor muscles, the crural diaphragm, and sympathetic vasomotor neurons is entrained to the postinspiratory (post-I) phase of the respiratory cycle, a mechanism thought to enhance cardiorespiratory efficiency. The identity of the central neurons responsible for transmitting respiratory activity to these outputs remains unresolved. Here we explore the contribution of the Kölliker-Fuse/parabrachial nuclei (KF-PBN) in the generation of post-I activity in vagal and sympathetic outputs under steady-state conditions and during acute hypoxemia, a condition that potently recruits post-I activity. In artificially ventilated, vagotomized, and urethane-anesthetized rats, bilateral KF-PBN inhibition by microinjection of the GABAA receptor agonist isoguvacine evoked stereotypical responses on respiratory pattern, characterized by a reduction in phrenic nerve burst amplitude, a modest lengthening of inspiratory time, and an increase in breath-to-breath variability, while post-I vagal nerve activity was abolished and post-I sympathetic nerve activity diminished. During acute hypoxemia, KF-PBN inhibition attenuated tachypneic responses and completely abolished post-I vagal activity while preserving respiratory-sympathetic coupling. Furthermore, KF-PBN inhibition disrupted the decline in respiratory frequency that normally follows resumption of oxygenation. These findings suggest that the KF-PBN is a critical hub for the distribution of post-I activities to vagal and sympathetic outputs and is an important contributor to the dynamic adjustments to respiratory patterns that occur in response to acute hypoxia. Although KF-PBN appears essential for post-I vagal activity, it only partially contributes to post-I sympathetic nerve activity, suggesting the contribution of multiple neural pathways to respiratory-sympathetic coupling.NEW & NOTEWORTHY Inhibition of neurons in the pontine Kölliker-Fuse/parabrachial complex (KF-PBN) differentially inhibited postinspiratory (post-I) activity in vagal and sympathetic outputs. The strong recruitment of post-I vagal activity that occurs in response to hypoxemia is selectively abolished by KF-PBN inhibition. This suggests that 1) post-I activity in vagal and sympathetic outputs may be generated by partially independent mechanisms and 2) neurons in the KF-PBN are a preeminent source of drive for the generation of eupneic post-I activity.

Bench assessment of PC-CMVs modes in transport and emergency ventilators under ICU conditions

Although there has been an increase in bench test evaluation of mechanical ventilators in recent years, a publication gap remains in assessing Pressure Control Continuous Mandatory Ventilation Modes with a set point targeting scheme PC-CMVs. This study evaluates the operational variability in PC-CMVs of eleven transport and emergency ventilators used in ICU units in Brazil during the COVID-19 pandemic. The assessment involved a comprehensive set of test scenarios derived from existing literature and the NBR ISO 80601-2-12:2014 standard. Nine parameters were computed for five consecutive breaths, offering a comprehensive characterization of pressure and flow waveforms. Most ventilators had Inspiratory pressure and PEEP values that fell outside of the tolerance ranges. Notably, three mechanical ventilators failed to reach the target pressures within the specified inspiratory times during test scenarios with a higher time constant (τ). We observed significant differences among emergency and transport ventilators in all assessed parameters, indicating a performance difference in PC-CMVs modes. The current results might help clinicians determine which ventilator models are suitable for specific clinical situations, particularly when unfavorable circumstances compel doctors to use ventilators that may not provide adequate support for patients in intensive care units.

Ventilatory and Perceived Ergogenic Effects of Mandibular Forward Repositioning During Running at Maximal Oxygen Uptake Intensity.

Cardoso, F, Costa, MJ, Colaço, P, Vilas-Boas, JP, Pinho, JC, Pyne, DB, and Fernandes, RJ. Ventilatory and perceived ergogenic effects of mandibular forward repositioning during running at maximal oxygen uptake intensity. J Strength Cond Res XX(X): 000-000, 2024-Wearing an intraoral dental splint may enhance ventilatory function and exercise performance. Nineteen runners performed on a 400-m outdoor track: (a) an incremental protocol to assess the velocity at maximal oxygen uptake (vV̇ o2 max) and (b) 2 square wave bouts wearing 2 intraoral splints (with and without mandibular forward repositioning). The time until exhaustion at vV̇ o2 max (TLimv V̇ o2 max), ventilatory variables, oxygen uptake (V̇ o2 ) kinetics, energetic profiling, perceived exertion and kinematics, were all measured. Ventilatory data were assessed breath-by-breath and perceived exertion evaluated using the Borg 6-20-point scale at the end of TLimv V̇ o2 max bouts. Images were recorded by video cameras (120 Hz) and kinematic measures retrieved using Kinovea. A paired t test was computed for comparison of splints ( p ≤ 0.05). With (vs. without) mandibular forward repositioning, runners increased their TLimv V̇ o2 max by ∼6% ( p = 0.03), coupled with higher ventilation (151 ± 22 vs. 147 ± 23 L·min -1 , p = 0.04), end-tidal oxygen tension (114.3 ± 3.7 vs. 112.9 ± 3.9 mm Hg, p = 0.003), and lower inspiratory time (0.526 ± 0.083 vs. 0.540 ± 0.090 seconds, p = 0.02), despite similar V̇ o2 kinetics (e.g., 49.0 ± 8.7 vs. 47.7 ± 8.6 ml∙kg∙min -1 of fast component amplitude) being observed. The energy expenditure was ∼8% higher ( p = 0.03) with the mandible forward, coupled with lower perceived exertion scores ( p = 0.04). Mandibular forward repositioning was effective in acutely improving running performance at vV̇ o2 max with ergogenic effects on ventilatory and perceived variables.

Inspiral time probability distribution for two black holes captured by emitting gravitational radiation

Inspiral time probability distribution for two black holes captured by emitting gravitational radiation

Post-insufflation diaphragm contractions in patients receiving various modes of mechanical ventilation

BackgroundDuring mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients’ characteristics or both.MethodsOne-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II.ResultsForty-seven patients (median[25%-75%IQR] age: 63[52–77] years, BMI: 24.9[22.9–33.7] kg/m2, 49% male, APACHE II: 21[19–28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05).ConclusionsIn critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.

Predictive value of diaphragm ultrasound for mechanical ventilation outcome in patients with acute exacerbation of chronic obstructive pulmonary disease.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is often combined with respiratory failure, which increases the patient's morbidity and mortality. Diaphragm ultrasound (DUS) has developed rapidly in the field of critical care in recent years. Studies with DUS monitoring diaphragm-related rapid shallow breathing index have demonstrated important results in guiding intensive care unit patients out of the ventilator. Early prediction of the indications for withdrawal of non-invasive ventilator and early evaluation of patients to avoid or reduce disease progression are very important. To explore the predictive value of DUS indexes for non-invasive ventilation outcome in patients with AECOPD. Ninety-four patients with AECOPD who received mechanical ventilation in our hospital from January 2022 to December 2023 were retrospectively analyzed, and they were divided into a successful ventilation group (68 cases) and a failed ventilation group (26 cases) according to the outcome of ventilation. The clinical data of patients with successful and failed noninvasive ventilation were compared, and the independent predictors of noninvasive ventilation outcomes in AECOPD patients were identified by multivariate logistic regression analysis. There were no significant differences in gender, age, body mass index, complications, systolic pressure, heart rate, mean arterial pressure, respiratory rate, oxygen saturation, partial pressure of oxygen, oxygenation index, or time of inspiration between patients with successful and failed mechanical ventilation (P > 0.05). The patients with successful noninvasive ventilation had shorter hospital stays and lower partial pressure of carbon dioxide (PaCO2) than those with failed treatment, while potential of hydrogen (pH), diaphragm thickening fraction (DTF), diaphragm activity, and diaphragm movement time were significantly higher than those with failed treatment (P < 0.05). pH [odds ratio (OR) = 0.005, P < 0.05], PaCO2 (OR = 0.430, P < 0.05), and DTF (OR = 0.570, P < 0.05) were identified to be independent factors influencing the outcome of mechanical ventilation in AECOPD patients. The DUS index DTF can better predict the outcome of non-invasive ventilation in AECOPD patients.

The role of respiratory function tests in infants with stridor: diagnosis at glance and follow-up

BackgroundRecently, the development of advanced, noninvasive methods has allowed the study of respiratory function even in uncooperative infants. To date, there is still little data on the application of this technique in infants with suspected airway obstruction. The aims of our study were:- To evaluate the role of respiratory function testing (PFR) in the diagnosis and follow-up of infants with stridor- To evaluate the differences between patients with inspiratory stridor and expiratory stridor.- To evaluate the concordance between PFR and endoscopy.MethodsWe enrolled infants aged < 1 year with a diagnosis of inspiratory and/or expiratory chronic stridor and a group of healthy controls. For each patient we performed PFR at diagnosis (T0) and for cases at follow-up, at 3 months (T1), 6 months (T2), 12 months (T3). At T0, all patients were classified according to a clinical score, and at follow-up, stature-ponderal growth was assessed.When clinically indicated, patients underwent bronchoscopy.ResultsWe enrolled 48 cases (42 diagnosed with inspiratory stridor and 6 expiratory stridor) and 26 healthy controls. At T0, patients with stridor had increased inspiratory time (p < 0.0001) and expiratory time (p < 0.001) than healthy controls and abnormal curve morphology depending on the type of stridor. At T0, patients with expiratory stridor had a reduced Peak expiratory flow (p < 0.023) and a longer expiratory time (p < 0.004) than patients with inspiratory stridor.We showed an excellent concordance between PFR and endoscopic examination (k = 0.885, p < 0.0001). At follow-up, we showed a progressive increase of the respiratory parameters in line with the growth.ConclusionsPFR could help improve the management of these patients through rapid and noninvasive diagnosis, careful monitoring, and early detection of those most at risk.

Predicting Successful Weaning through Sonographic Measurement of the Rapid Shallow Breathing Index.

Background: Diaphragmatic dysfunction correlates with weaning failure, highlighting the need to independently assess the diaphragm's effects on weaning. We modified the rapid shallow breathing index (RSBI), a predictor of successful weaning, by incorporating temporal variables into existing ultrasound-derived diaphragm index to create a simpler index closer to tidal volume. Methods: We conducted a prospective observational study of patients who underwent a spontaneous breathing trial in the medical intensive care unit (ICU) at Severance Hospital between October 2022 and June 2023. Diaphragmatic displacement (DD) and diaphragm inspiratory time (Ti) were measured using lung ultrasonography. The modified RSBI was defined as follows: respiratory rate (RR) divided by DD was defined as D-RSBI, and RR divided by the sum of the products of DD and Ti on both sides was defined as DTi-RSBI. Results: Among the sonographic indices, DTi-RSBI had the highest area under the receiver operating characteristic (ROC) curve of 0.774 in ROC analysis, and a correlation was found between increased DTi-RSBI and unsuccessful extubation in a multivariable logistic regression analysis (adjusted odds ratio 0.02, 95% confidence interval 0.00-0.97). Conclusions: The DTi-RSBI is beneficial in predicting successful weaning in medical ICU patients.

Diagnosis of patients with chronic heart failure implementing wavelet transform and machine learning techniques

Chronic heart failure (CHF) is a significant public health concern due to its increasing prevalence, high number of hospital admissions, and associated mortality. Its prevalence is progressively increasing due to the aging of the population and the decrease in mortality from acute myocardial infarction, among other medical advancements. Consequently, the incidence of CHF predominantly affects older age groups, doubling its prevalence every decade, becoming one of the main causes of mortality in patients older than 65 years. The main objective of this study is to apply machine learning based techniques to determine the best models to classify patients with chronic heart failure through their respiratory pattern. These patterns have been characterized from time series such as inspiratory and expiratory times, breathing duration, and tidal volume obtained from the respiratory flow signal. Based on the behavior of the respiratory pattern, CHF patients were classified into patients with non-periodic breathing, with periodic breathing, and with Cheyene-Stokes respiration (CSR). Time-frequency and statistical techniques have been implemented to analyze these features, and then various classification methods have been applied to define the optimal model with the best accuracy rates. These models could help to better understand the evolution of this disease and in early diagnosis.

Respiratory physiological mechanism of two types of equal-intensity inspiratory muscle training in stable patients with chronic obstructive pulmonary disease

PurposeThis study aimed to investigate the respiratory physiological changes resulting from short-term inspiratory resistance training (R-IMT) and inspiratory threshold training (T-IMT) in patients with chronic obstructive pulmonary disease (COPD) and to compare the mechanisms of the two training methods. Patients and methodsA total of 75 stable patients with COPD combined with inspiratory muscle weakness were randomly allocated to three groups: R-IMT (n = 26), T-IMT (n = 24), and control (n = 25). Before and after 8 weeks of inspiratory muscle training(IMT), cardiopulmonary exercise tests were conducted to assess respiratory patterns, respiratory central drive, exercise tolerance, and ventilation efficiency. ResultsAfter 8 weeks of IMT, Inspiratory muscle strength, represented by MIP (maximum inspiratory mouth pressure) and exercise capacity increased during exercise in both IMT groups (P < 0.05). In the R-IMT group, inspiratory time (Ti) prolonged (P < 0.05), tidal volume (Vt) increased (P < 0.05), ventilation efficiency (represented by ventilation-center coupling) increased (P < 0.05) during exercise. Conversely, the T-IMT group did not exhibit any of these changes after IMT (P > 0.05). ConclusionIn summary, the improvement in exercise tolerance was associated with an increase in inspiratory muscle reserve in both R-IMT and T-IMT. However, only R-IMT was associated with deeper and slower breathing, as well as improved ventilation efficiency.

Workload and spirometry associated with untethered swimming in horses

BackgroundSwimming has been used empirically for rehabilitation and conditioning of horses. However, due to challenges imposed by recording physiological parameters in water, the intensity of free swimming effort is unknown.ObjectivesMeasure the physiological workload associated with untethered swimming in horses.Five fit Arabian endurance horses were assessed while swimming in a 100 m-long indoor pool. Horses were equipped with a modified ergospirometry facemask to measure oxygen consumption (V̇O2) and ventilatory parameters (inspired/expired volumes, VI, VE; peak inspiratory/expiratory flows, PkVI, PkVE; respiratory frequency, Rf; minute ventilation, VE; inspiratory/expiratory durations and ratios, tI, tE, tI/ttot, tE/ttot); and an underwater electrocardiogram that recorded heart rate (HR). Postexercise venous blood lactate and ammonia concentrations were measured. Data are reported as median (interquartile ranges).ResultsHorses showed bradypnea (12 breaths/min (10–16)) for the first 30 s of swimming. V̇O2 during swimming was 43.2 ml/(kg.min) (36.0–56.6). Ventilatory parameters were: VI = 16.7 L (15.3–21.8), VE = 14.7 L (12.4–18.9), PkVI = 47.8 L/s (45.8–56.5), PkVE = 55.8 L/s (38.3–72.5), Rf = 31.4 breaths/min (20.0–33.8), VE = 522.9 L/min (414.7–580.0), tI = 0.5 s (0.5–0.6), tE = 1.2 s (1.1–1.6), tI/ttot = 0.3 (0.2–0.4), tE/ttot = 0.7 (0.6–0.8). Expiratory flow tracings showed marked oscillations that coincided with a vibrating expiratory sound. HR was 178.0 bpm (148.5–182.0), lactate = 1.5 mmol/L (1.0–1.9) and ammonia = 41.0 µmol/L (36.5–43.5).ConclusionsFree (untethered) swimming represents a submaximal, primarily aerobic exercise in horses. The breathing pattern during swimming is unique, with a relatively longer apneic period at the beginning of the exercise and an inspiratory time less than half that of expiration.

How to Prevent Ventilator-Induced Lung Injury in Intraoperative Mechanical Ventilation? A Randomized Prospective Study.

Intraoperative mechanical ventilation practices can lead to ventilator-induced lung injury (VILI) and postoperative pulmonary complications in healthy lungs. Mechanical power (MP) has been developed as a new concept in reducing the risk of postoperative pulmonary complications as it considers all respiratory mechanics that cause VILI. The most commonly used intraoperative modes are volume control ventilation (VCV) and pressure control ventilation (PCV). In this study, VCV and PCV modes were compared in terms of respiratory mechanics in patients operated in the supine and prone positions. The patients were divided into 4 groups (80 patients), volume control supine and prone, pressure control supine and prone with 20 patients each. MP, respiratory rate, positive end-expiratory pressure, tidal volume, peak pressure, plato pressure, driving pressure, inspiratory time, height, age, gender, body mass index, and predictive body weight data of the patients included in the groups have been obtained from "electronic data pool" with Structured Query Language queries. The supine and prone MP values of the VCV group were statistically significantly lower than the PCV group (P values were 0.010 and 0.001, respectively). Supine and prone MP values of the VCV group were calculated significantly lower than the PCV group. Intraoperative PCV may be considered disadvantageous regarding the risk of VILI in the supine and prone positions.

Discrete orbit effect lengthens merger times for inspiraling binary black holes

The inspiral merger time for two black holes captured into a nonrelativistic bound orbit by gravitational radiation emission has been often calculated by a formula of Peters that assumes the adiabatic approximation that the changes per orbit are small. However, initially this is not true for the semimajor axis and period of most of the initially highly eccentric orbits, which change significantly during closest approach and much less elsewhere along the orbit. This effect can make the merger time much longer (using other formulas from Peters that do not assume the adiabatic approximation) than that calculated by the adiabatic formula of Peters.

A Magnetic Field-Based Wearable Respiration Sensor for Real-Time Monitoring During Pulmonary Rehabilitation.

This work explores Hall effect sensing paired with a permanent magnet, in the context of pulmonary rehabilitation exercise training. Experimental evaluation was performed considering as reference the gold-standard of respiratory monitoring, an airflow transducer, and performance was compared to another wearable device with analogous usability - a piezoelectric sensor. A total of 16 healthy participants performed 15 activities, representative of pulmonary rehabilitation exercises, simultaneously using all devices. Evaluation was performed based on detection of flow reversal events and key respiratory parameters. Overall, the proposed sensor outperformed the piezoelectric sensor with a mean ratio, precision, and recall of 0.97, 0.97, and 0.95, respectively, against 0.98, 0.90, and 0.88. Evaluation regarding the respiratory parameters indicates an adequate accuracy when it comes to breath cycle, inspiration, and expiration times, with mean relative errors around 4% for breath cycle and 8% for inspiration/expiration times, despite some variability. Bland-Altman analysis indicates no systematic biases. Characterization of the proposed sensor shows adequate monitoring capabilities for exercises that do not rely heavily on torso mobility, but may present a limitation when it comes to activities such as side stretches. This work provides a comprehensive characterization of a magnetic field-based respiration sensor, including a discussion on its robustness to different algorithm thresholds. It proves the viability of the sensor in a range of exercises, expanding the applicability of Hall effect sensors as a feasible wearable approach to real-time respiratory monitoring.

Mean airway pressure - Minute ventilation product (mM): A simple and universal surrogate equation to calculate mechanical power in both volume and pressure controlled ventilation

Introduction Mechanical power represents the energy delivered by a mechanical ventilator onto the lungs. It incorporates all the variables participating in ventilator-induced lung injury, including driving pressure, tidal volume, positive end expiratory pressure, and respiratory rate. The pitfall of mechanical power is its mathematical complexity, as the gold standard method of calculation involves deriving the inspiratory area under the pressure-volume curve of each breath. Prior studies attempted to create simplified equations, they lack clinical utility as calculations cannot be done by solely looking at ventilator settings or they require manipulation of variables. There are also different formulas depending on the type of the mode of ventilation used. This study offers a simplified, universal equation called the mean airway pressure - Minute ventilation product (mM equation) which renders mechanical power clinical application more feasible at the bedside. Methods and Statistics Data collection used the online SIVA simulator, which simulate mechanical ventilation and calculate the geometrical area of the inspiratory limb of the pressure-volume curve. Different combinations of passive scenarios with varying compliances (10-80 ml/cmH2O) and resistances (5-30 cmH2O/L/S) in each the VCV and PCV modes were accomplished by adjusting ventilator settings with respiratory rate (5-40 BPM), tidal volume (150-700 mL), DP (5-30 cmH2O), and PEEP (0-15 cmH2O), with different inspiratory times in PCV and different flows rates in the VCV. A total of 2,000 values were collected in each mode. Range of Mechanical power measured by the simulator: 0.1 - 105 J/min and range of mM equation (mean airway pressure x Minute ventilation): 0.37 - 820 cmH2O/L/min. Pearson correlation coefficients were calculated to compare the relationship of the mM equation to the measured MP, and linear regressions were used for predicting the MP derived from the mM equation in each mode separately and when combining all data from both modes. T-test for equal variance and Bland Altmann plot were used to compare the reference MP measured (MPR) from the simulator to the one derived from the Mm formula (MPD). Results There was a statistically significant linear relationship (P &lt; 0.001) and strong correlation of determination (R2 = 0.931), CI (0.961, 0.967) between the mM formula and the gold-standard method of calculating mechanical power for the combined two modes. For the VCV: there was a statistically significant linear relationship (P &lt; 0.001) and strong correlation of determination (R2 = 0.936), CI (-0.963, 0.971). For the PCV: there was a statistically significant linear relationship (P &lt; 0.001) and strong correlation of determination (R2 = 0.936), CI (-0.964, 0.970). A linear regression model predicted the MP from the mM as follows: for both modes MP = 0.13 (mM) + 3.41, for PCV MP = 0.15 (mM) + 3.79, for VCV MP = 0.13 (mM) + 2.48. The derived mechanical power from the mM was not statistically different (P 0.498) from the calculated reference MP using two sample T-tests assuming equal variance. The Bland-Altman plot for VCV mode showed a mean of 0.78 with 95% CI (0.34, 1.22), SD (-13.27, 14.83). In PCV, a mean of - 0.53 with 95% CI (-0.68, -0.38), SD (-6.28, 5.22). For both modes, a mean of 0, with 95% CI (-0.2, 0.2), SD (-10.06, 10.05). Conclusion The mM equation and its MP derived formula is a reliable method of calculating mechanical power. The simplicity and universal nature of its calculation can provide significant clinical utility at the bedside. More studies are needed to validate this method of calculation. Keywords: Mechanical power, mean airway pressure, minute ventilation

The new neural pressure support (NPS) mode and the helmet: did we find the dynamic duo?

BackgroundNoninvasive ventilation (NIV) is commonly used in clinical practice to reduce intubation times and enhance patient comfort. However, patient-ventilator interaction (PVI) during NIV, particularly with helmet interfaces, can be challenging due to factors such as dead space and compliance. Neurally adjusted ventilatory assist (NAVA) has shown promise in improving PVI during helmet NIV, but limitations remain. A new mode, neural pressure support (NPS), aims to address these limitations by providing synchronized and steep pressurization. This study aims to assess whether NPS per se improves PVI during helmet NIV compared to standard pressure support ventilation (PSV).MethodsThe study included adult patients requiring NIV with a helmet. Patients were randomized into two arms: one starting with NPS and the other with PSV; the initial ventilatory parameters were always set as established by the clinician on duty. Physiological parameters and arterial blood gas analysis were collected during ventilation trials. Expert adjustments to initial ventilator settings were recorded to investigate the impact of the expertise of the clinician as confounding variable. Primary aim was the synchrony time (Timesync), i.e., the time during which both the ventilator and the patient (based on the neural signal) are on the inspiratory phase. As secondary aim neural-ventilatory time index (NVTI) was also calculated as Timesync divided to the total neural inspiratory time, i.e., the ratio of the neural inspiratory time occupied by Timesync.ResultsTwenty-four patients were enrolled, with no study interruptions due to safety concerns. NPS demonstrated significantly longer Timesync (0.64 ± 0.03 s vs. 0.37 ± 0.03 s, p < 0.001) and shorter inspiratory delay (0.15 ± 0.01 s vs. 0.35 ± 0.01 s, p < 0.001) compared to PSV. NPS also showed better NVTI (78 ± 2% vs. 45 ± 2%, p < 0.001). Ventilator parameters were not significantly different between NPS and PSV, except for minor adjustments by the expert clinician.ConclusionsNPS improves PVI during helmet NIV, as evidenced by longer Timesync and better coupling compared to PSV. Expert adjustments to ventilator settings had minimal impact on PVI. These findings support the use of NPS in enhancing patient-ventilator synchronization and warrant further investigation into its clinical outcomes and applicability across different patient populations and interfaces.Trial registrationThis study was registered on www.clinicaltrials.gov NCT06004206 Registry URL: https://clinicaltrials.gov/study/NCT06004206 on September 08, 2023.

Tidal volume selection in volume-controlled ventilation guided by driving pressure versus actual body weight in healthy anesthetized and mechanically ventilated dogs: A randomized crossover trial

ObjectiveTo compare static compliance of the respiratory system (CstRS) and the ratio of partial pressure of end-tidal to arterial carbon dioxide (Pe′CO2/PaCO2), in healthy dogs using two approaches for tidal volume (VT) selection during volume-controlled ventilation: body mass based and driving pressure (ΔPaw) guided. Study designRandomized, nonblinded, crossover, clinical trial. AnimalsA total of 19 client-owned dogs anesthetized for castration and ovariohysterectomy. MethodsAfter a stable 10 minute baseline, each dog was mechanically ventilated with a VT selection strategy, randomized to a constant VT of 15 mL kg–1 of actual body mass (VTBW) or ΔPaw-guided VT (VTΔP) of 7–8 cmH2O. Both strategies used an inspiratory time of 1 second, 20% end-inspiratory pause, 4 cmH2O positive end-expiratory pressure and fraction of inspired oxygen of 0.4. Respiratory frequency was adjusted to maintain Pe′CO2 between 35 and 40 mmHg. Respiratory mechanics, arterial blood gases and Pe′CO2/PaCO2 were assessed. Continuous variables are presented as mean ± SD or median (interquartile range; quartiles 1–3), depending on distribution, and compared with Wilcoxon signed-rank tests. ResultsThe VT was significantly higher in dogs ventilated with VTΔP than with VTBW strategy (17.20 ± 4.04 versus 15.03 ± 0.60 mL kg–1, p = 0.036). CstRS was significantly higher with VTΔP than with VTBW strategy [2.47 (1.86–2.86) versus 2.25 (1.79–2.58) mL cmH2O−1 kg–1, p = 0.011]. There were no differences in Pe′CO2/PaCO2 between VTΔP and VTBW strategies (0.94 ± 0.06 versus 0.92 ± 0.06, p = 0.094). No discernible difference in ΔPaw was noted between the strategies. Conclusions and clinical relevanceWhile no apparent difference was observed in the Pe′CO2/PaCO2 between the VT selection strategies employed, CstRS significantly increased during the VTΔP approach. A future trial should explore if VTΔP improves perioperative gas exchange and prevents lung damage.