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Limited predictability of maximal muscular pressure using the difference between peak airway pressure and positive end-expiratory pressure during proportional assist ventilation (PAV)
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Limited predictability of maximal muscular pressure using the difference between peak airway pressure and positive end-expiratory pressure during proportional assist ventilation (PAV)
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Journal Article
Limited predictability of maximal muscular pressure using the difference between peak airway pressure and positive end-expiratory pressure during proportional assist ventilation (PAV)
2016
Overview
Background
If the proportional assist ventilation (PAV) level is known, muscular effort can be estimated from the difference between peak airway pressure and positive end-expiratory pressure (PEEP) (ΔP) during PAV. We conjectured that deducing muscle pressure from ΔP may be an interesting method to set PAV, and tested this hypothesis using the oesophageal pressure time product calculation.
Methods
Eleven mechanically ventilated patients with oesophageal pressure monitoring under PAV were enrolled. Patients were randomly assigned to seven assist levels (20–80%, PAV20 means 20% PAV gain) for 15 min. Maximal muscular pressure calculated from oesophageal pressure (P
mus, oes
) and from ΔP (P
mus, aw
) and inspiratory pressure time product derived from oesophageal pressure (PTP
oes
) and from ΔP (PTP
aw
) were determined from the last minute of each level. P
mus, oes
and PTP
oes
with consideration of PEEPi were expressed as P
mus, oes, PEEPi
and PTP
oes, PEEPi
, respectively. Pressure time product was expressed as per minute (PTP
oes
, PTP
oes, PEEPi
, PTP
aw
) and per breath (PTP
oes, br
, PTP
oes, PEEPi, br
, PTP
aw, br
).
Results
PAV significantly reduced the breathing effort of patients with increasing PAV gain (PTP
oes
214.3 ± 80.0 at PAV20 vs. 83.7 ± 49.3 cmH
2
O•s/min at PAV80, PTP
oes, PEEPi
277.3 ± 96.4 at PAV20 vs. 121.4 ± 71.6 cmH
2
O•s/min at PAV80,
p
< 0.0001). P
mus, aw
overestimates P
mus, oes
for low-gain PAV and underestimates P
mus, oes
for moderate-gain to high-gain PAV. An optimal P
mus, aw
could be achieved in 91% of cases with PAV60. When the PAV gain was adjusted to P
mus, aw
of 5–10 cmH
2
O, there was a 93% probability of PTP
oes
<224 cmH
2
O•s/min and 88% probability of PTP
oes, PEEPi
< 255 cmH
2
O•s/min.
Conclusion
Deducing maximal muscular pressure from ΔP during PAV has limited accuracy. The extrapolated pressure time product from ΔP is usually less than the pressure time product calculated from oesophageal pressure tracing. However, when the PAV gain was adjusted to P
mus, aw
of 5–10 cmH
2
O, there was a 90% probability of PTP
oes
and PTP
oes, PEEPi
within acceptable ranges. This information should be considered when applying ΔP to set PAV under various gains.
Publisher
BioMed Central,BioMed Central Ltd,Springer Nature B.V
