The Influence of Altered Pulmonarv

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1 The Influence of Altered Pulmonarv J Mechanics on the Adequacy of Controlled Ventilation Peter Hutchin, M.D., and Richard M. Peters, M.D. W ' hereas during spontaneous respiration the individual determines his own rate and tidal volume, careful regulation of these two respiratory parameters is necessary during artificial ventilation to effect optimal gas exchange. In particular, the tidal volume delivered must be carefully controlled by application of adequate pressure to the airway. Since changes in pulmonary mechanics accompanying operation and trauma or those resulting from excessive obesity alter the pressures required to inflate and deflate the lungs, understanding of the effects of such changes on the respiratory system is necessary for rational use of ventilators. In the work reported here, a simple mechanical analog of the respiratory system [4] was used to study the effects of changes in tidal volume and rate on the effectiveness of mechanical ventilatory support in the presence of altered compliance or airway resistance and mass loading (obesity) of the respiratory system. MATERIALS AND METHODS THE MECHANICAL RESPIRATORY SYSTEM As described in a previous communication [41, the mechanical respiratory system consisted of a 9-liter Collins spirometer restricted in its rise by elastic rubber bands and connected to the respirator by means of tubing into which various resistors could be inserted. The tidal volume delivered by the respirator* was measured from the spirometer pen deflection. The end-expiratory volume remaining in the spirometer represented the residual volume. Pressures were measured on both sides of the resistance inserted in the tubing connecting the respirator with the spirometer. The pressure measured between the respirator and the resistance represented the pressure at the opening of the airway (pressure at the mouth). The pressure measured between the resistance and the spirometer represented the alveolar pressure. The rate of the respirator was set at 20 respirations per minute, with an inspiration-expiration ratio of 1 : 2 or 2 : 1. As the tidal volume was varied from 0 to 1,000 cc., the peak inspiratory From the Division of Thoracic and Cardiovascular Surgery, School of Medicine, University of North Carolina, Chapel Hill, N.C. Accepted for publication Dec. 13, 'The Emerson volume-preset, time-cycled respirator was used in this study. 302 THE ANNALS OF THORACIC SURGERY

2 Mechanics of Controlled Ventilation mouth and alveolar pressures and the end-expiratory alveolar pressures were determined at various settings of compliance, airway resistance, and dead weight. COMPLIANCE The compliance of the system was varied using rubber restraints of different strengths. After initial testing, three restraints were selected to correspond to a compliance of liter per centimeter (representing normal lungs alone and simulating compliance when the chest is opened), liter per centimeter (representing normal lungs and chest wall, or decreased compliance of lungs alone), and liter per centimeter (representing decreased compliance of lungs and chest wall). RESISTANCE Three inserts representing normal, moderately increased, and markedly increased resistance were used in the tubing connecting the respirator to the spirometer. The resistance of these inserts increased linearly as flow rate increased. With a flow rate of 0.5 liter per second, the resistance of the inserts was 1, 4, and 8 cm. H,O per liter per second, respectively; with a flow rate of 1 liter per second, the resistance increased to 7, 13, and 35 cm. H20 per liter per second. DEAD WEIGHT The effect of obesity on this mechanical respiratory system was simulated by placing weights on top of the spirometer bell. Weights of 0.91 kg., 1.82 kg., and 2.73 kg. were placed on top of the spirometer bell to simulate three degrees of obesity. To lift these weights required a mean force of 2.1 cm. H,O, 3.8 cm. H20, and 5.7 cm. H,O, respectively. RESULTS AND INTERPRETATION COMPLIANCE As the compliance was decreased from liter per centimeter (normal lungs alone) to liter per centimeter (normal lungs and chest wall), the peak inspiratory pressure necessary to inflate the system over the range of tidal volume rose (Fig. 1). The relationship between peak inspiratory mouth pressure and the volume delivered was roughly linear. Each compliance curve had a different slope. As the compliance decreased, the slope became steeper, so that more pressure was necessary to deliver a given tidal volume. DEAD WEIGHT The effect of increased dead weight on the peak inspiratory mouth pressure for two different compliances (0.075 and liter per centimeter) is also shown in Figure 1. With added dead weight, greater inspiratory pressure was necessary to deliver a given tidal volume into the spirometer without change of the compliance. The more dead weight that was added, the greater was the inspiratory pressure necessary to inflate the spirometer. Over the range of tidal volumes examined (0-1,000 cc.), this relationship between dead weight and inspiratory pressure was linear; the pressure required to start inflation was increased in direct proportion to the amount of dead weight added. This occurred without a change in compliance. RESISTANCE The effect of normal, moderately increased, and markedly increased airway resistance on the peak inspiratory mouth and alveolar and end-expiratory alveolar pressure is shown in Figure 2. The greater the airway resistance, the greater VOL. 7, NO. 4, APRIL,

3 HUTCHIN AND PETERS 0 1 I I I Q zij w Roo 1000,2IJ0 Tidal Volume FIG. 1. The influence of changing compliance and dead weight on the peak inspiratory pressure necessary to inflate the lungs at uarious tidal volumes. Curues labelcd A represent the addition of 0.91 kg. weight to the spirometer; the curue labelcd B represents the addition of 2.73 kg. weight. Dashed line, compliance of normal lungs alone (0.175 liter per centimeter); solid lines, compliance of normal lungs and chest wall (0.075 liter per centimeter); dotted lines, decreased compliance of lungs and chest wall (0.038 liter per centimeter). As the compliance decreases, the pressure-volume slope becomes steeper and more pressure is necessary to deliver a given tidal volume. The eflect of increased dead weight is to move up the compliance curue on its pressure axis in direct proportion to the dead weight added, without changing its slope. (ml.) was the pressure rise as the tidal volume was increased. The peak inspiratory mouth pressure increased because flow rate increased, and so pressure necessary to overcome the resistance had to rise. The greater the resistance, the greater was the pressure necessary to overcome it. The peak inspiratory alveolar pressure equaled the pressure at the mouth minus the interposed resistance. It rose only as a result of rise in the end-expiratory alveolar pressure, which reflected the amount of residual air accumulating in the spirometer at various tidal volume settings. To accept a given tidal volume, the lungs therefore had to be stretched more. With normal airway resistance there was no accumulation of residual volume in the system, and the end-expiratory alveolar pressures remained near zero. As the airway resistance was increased and residual volume developed at higher tidal volumes, the end-expiratory alveolar pressure rose. RESIINJAL AIR The effect of increasing airway resistance on residual air accumulating in the spirometer at various tidal volumes is shown in Figure 3. As the airway resistance increased, insufficient time was available during passive expiration for 304 THE ANNALS OF THORACIC SURGERY

4 Mechanics of Controlled Ventilation SO 45 ia Tidrl \'.,lumc ("31.1 FIG. 2. The influence of changing airway resistance. Solid line, normal airway resistance; dotted line, moderate airway resistance; dashed line, marked airway resistance. For each airway resistance, three curves are plotted. Curves marked A represent the peak inspiratory mouth pressure; B, the peak inspiratory alveolar pressure; and C, the end-expiratory alveolar pressure in the lungs at various tidal volumes. The compliance of the system is that of normal lungs and chest wall (0.075 liter per centimeter). The greater the resistance, the greater is the Peak inspiratory mouth pressure, A, necessary to overcome it. The peak inspiratory alveolar pressure, B, is the pressure at the mouth minus the pressure dissipated by the interposed resistance. It is increased in the marked airway and moderate airway resistance over normal in proportion to the increase in the end-expiratory alveolar pressure, C, which reflects the amount of residual air that accumulates as airway resistance is increased. deflation of the spirometer, and residual air accumulated in the system. Accumulation of residual air at any given airway resistance could be reduced by increasing the amount of dead weight and decreasing the compliance. Thus, both increased dead weight and decreased compliance aided exhalation, lowering end-expiratory residual volume and end-expiratory alveolar pressure. INSPIRATION-EXPIRATION RATIO The effect of the duration of expiration on the peak inspiratory mouth and alveolar pressures and end-expiratory alveolar pressure and residual air is shown in Figure 4. With a normal lung and chest wall compliance and normal airway resistance, residual air did not accumulate when the duration of the passive expiratory phase was twice that of the inspiratory phase. When the expiratory time was shortened to one-half of the inspiratory time, residual air accumulated as the tidal volume increased. The alveolar pressures at peak inspiration and at the end of expiration increased parallel with the increased volume of residual air remaining in the system. VOL. 7, NO. 4, APRIL,

5 HUTCHIN AND PETERS Tidnl Volume (ml.) FIG. 3. The influence of changing airway resistance and dead weight on accumulation of residual air in the lungs. The compliance is the same for all curzles (0.075 liter per centimeter). Solid line, normal resistance; dotted line, moderately increased resistance; dashed lines, markedly increased resistance. Curve labeled A represents markedly increased resistance with 0.91 kg. of added dead weight, and B represents markedly increased resistance with 2.73 kg. of added dead weight. As airway resistance increases, insuficient time is available for passive deflation, and residual air accumulates. The amount of residual air can be reduced for any given airway resistance by increasing the amount of dead zueight. Figure 4 demonstrates, also, the effect of increasing the duration of inspiration. This allows more time for any given tidal volume to be delivered and consequently lowers the peak inspiratory mouth pressure necessary to inflate the system. When inspiration is short, the respirator must work harder to deliver the desired tidal volume. When inspiration is long, the peak inspiratory mouth pressure can be lowered, as more time is available to deliver the tidal volume. DISCUSSION Lung compliance is altered during and following thoracic and upper abdominal surgical procedures because of small areas of collapse and consolidation or because of direct trauma to the lung [3]. In addition, the chest wall compliance falls due to muscle spasm and edema. A decrease in compliance makes the lung and chest wall stiffer; consequently, the volume of air that can be introduced into the lung per 1 cm. of water pressure becomes smaller. Airway resistance may be elevated because of accumulation of secretions in the tracheobronchial tree or because of bronchoconstriction. The increased resistance retards the rate of air flow into and out of the lungs during the respiratory cycle, making ventilation less efficient. In obese patients, added force is required to lift the heavy chest and abdominal wall. 306 THE ANNALS OF THORACIC SURGERY

6 Mechanics of Controlled Ventilation m IS wo 8M) loo0 Tidd Volume (ml.) FIG. 4. The influence of the duration of inspiration and expiration. The solid line indicates an inspiration-expiration ratio of 1 : 2 (expiration time, 2 seconds); the dotted line indicates an inspiration-expiration ratio of 2 : 1 (expiration time, 1 second). Curves labeled A represent the peak inspiratory mouth pressure; B, peak inspiratory alveolar pressure; and C, end-expiratory alveolar pressure in the lungs at various tidal volumes. The system is ventilated at 20 breaths per minute, the airway resistance is normal, and the compliance is that of normal lungs and chest wall (0.075 liter per centimeter). With an inspiration-expiration ratio of 1 : 2, there is no residual volume. When the duration of passive expiration is shortened (inspiration-expiration ratio, 2 : I), residual air accumulates as tidal volume increases (bar graphs). Alveolar pressures increase parallel with the increasing residual volume. When inspiratory time is long, the peak inspiratory mo,iith pressure (A) is lower, since more time is allowed to deliver the tidal volume. For a given tidal volume and respiratory rate, compliance of the lungs and the chest wall, dead weight of the chest wall and abdomen, and resistance to air flow will determine the pressure required in the airway for inspiration. In children it must be remembered that the small diameter of the chest makes the compliance much less than in adults, so that children require inspiratory pressures equal to those of adults despite the smaller required tidal volumes. The alveolar inspiratory pressure will be lower than the inspiratory pressure at the mouth in direct proportion to the airway resistance. The end-expiratory alveolar pressure will approximate atmospheric pressure except when residual volume accumulates in the lungs because of increased airway resistance or short duration of expiration. When a volume-preset respirator is used, the tidal volume and rate are set on the respirator, and the pressures developed will be determined by the patient s lung characteristics. The respirator must be able to generate sufficient pressure to effect an adequate tidal exchange. Decreased compliance increases the slope of the pressure-volume curve, so that at any given tidal volume more pressure is necessary to VOL. 7, NO. 4, APRIL,

7 HUTCHIN AND PETERS effect the tidal exchange. This is in contrast to increasing the dead weight, which increased the pressures necessary to start inflation of the system but does not change the slope of the pressure-volume curve. In the obese patient, the heavy chest and abdominal wall oppose the inflation by the respirator, which must work harder to achieve a higher peak inspiratory pressure and deliver the tidal volume into the alveoli. If the airway resistance is unchanged, the peak inspiratory alveolar pressure also becomes elevated, since the pressure drop between the mouth and the alveoli remains the same. Just as the increased weight of adipose tissues hinders inflation of the lungs, it will aid deflation during expiration and reduce the amount of residual air that accumulates. Low compliance has a similar effect and aids exhalation. Increasing the airway resistance or decreasing the duration of expiration, on the other hand, have an opposite effect; exhalation is hindered and residual air accumulates. The effect of increased airway resistance necessitates an increase in the peak inspiratory mouth pressure, demanding that the respirator work harder to deliver a given tidal volume. This increased inspiratory pressure at the mouth is dissipated in the airways in overcoming the frictional resistance, and the inspiratory alveolar pressure will not be increased. At higher tidal volumes, when passive expiration is insufficiently long to empty the lungs prior to another inspiration, residual air will accumulate and the inspiratory and end-expiratory alveolar pressures will become elevated. Although the product of compliance and resistance (time constant) has been useful in determining the shortest expiratory time that will not result in an accumulation of residual air [I], this useful theoretical concept alone is not enough in practice. Other factors, such as mass loading of the thorax (obesity), are of great importance. When mechanical ventilation is employed, continuous surveillance of the adequacy of the patient s tidal exchange and frequent monitoring of arterial blood gases are essential for proper care. At the same time, one must understand the limits of performance of the respirator used. SUMMARY The effects of changes in compliance, airway resistance, and mass loading (obesity) of the respiratory system were studied during controlled ventilation on a simple mechanical analog of the respiratory system. The Emerson volume-preset, time-cycled respirator was used. Decreased compliance and increased dead weight increased the inflation pressures necessary to deliver a given tidal volume but accelerated exhalation. Elevated airway resistance increased the inflation pressure and residual 308 THE ANNALS OF THORACIC SURGERY

8 Mechanics of Controlled Ventilation air, with resulting increase in alveolar end-expiratory pressure and hyperinflation of the system. This effect was also produced by a short expiratory time inadequate for complete emptying of the system. REFERENCES 1. Clements, J. H. Respiratory Mechanics in Resuscitation. In J. L. Whittenberger (Ed.), Artificial Respiration. New York: Harper & Row, Publishers, Pp Mapleson, W. W. The effect of changes of lung characteristics on the functioning of automatic ventilators. Anaesthesia 17:300, Okinaka, A. J. Postoperative pattern of breathing and compliance. Arch. Surg. (Chicago) 92:887, Peters, R. M., and Hutchin, P. Adequacy of available respirators to their tasks. Ann. Thorac. Surg. 3:414, NOTICE FROM THE BOARD OF THORACIC SURGERY The 1969 fall examinations will be given as follows: Written Examination. To be held at various centers throughout the country on September 5, Final date for filing applications is June 1, Oral Exumination. To be given in October, 1969, in Oakland, Calif. Final date for filing applications is June 1, Please address all communications to the Board of Thoracic Surgery, Inc., 1151 Taylor Ave., Detroit, Mich VOL. 7, NO. 4, APRIL,

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