PEEPi. (physiology); system; Cst,rs = effective static compliance of the respiratory system; Rrs = additional (non-ohmic) resistance

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1 CHEST Peter Doelken, MD, FCCP; Ricardo Abreu, MD, FCCP; Steven A. Sahn, MD, FCCP; and Paul H. Mayo, MD, FCCP (9 ) (Cst,rs) (Wv) PCO 2 (Pliq) Wv Pliq Cst,rs ( ) (PEEPi) Wv Pliq PEEPi (mechanical ventilation); (physiology); (thoracentesis) Cc = static compliance of the ventilator circuit; Cdyn,rs = dynamic compliance of the respiratory system; Cst,rs = effective static compliance of the respiratory system; Rrs = additional (non-ohmic) resistance of the respiratory system; V = volume change; Est,pl = pleural space elastance during entire thoracentesis; Est,pl,.5 = pleural space elastance during withdrawal of first 5 ml of fluid; FIO 2 = fraction of inspired oxygen; P1 = intercept of a computer-fitted third-order polynomial equation of the slow pressure decline and a vertical line indicating the time of onset of valve closure; P(A-a)O 2 = alveolar-arterial oxygen pressure difference; PEEP = positive end-expiratory pressure; PEEPi = intrinsic positive end-expiratory pressure; Pliq = pleural liquid CHEST

2 pressure; Ppeak = peak pressure; Pplat = plateau pressure; Rinit,rs = ohmic resistance of the respiratory system; Rmax,rs = effective interrupter resistance of the respiratory system; VD /VT = dead space fraction; VT = tidal volume; Wv = work performed by the ventilator 3 min [1 4] 15 min (Cc) = 1.69 ml / cm H 2 O (FIO 2 ) 1. (VT) 5 ml 6 L / min ( ICU ) 8 PEEP (PEEPi) 3 4 PEEP 5 cm H 2 O PEEP cmh 2 O PEEPi 5 / min ( ) PEEP 5 ( a 7b) Ppeak Pplat PEEPi 8 (Puritan-Bennett 72 Puritan-Bennett Corporation; Ppeak Pplat Carlsbad CA) PEEPi From the Division of Pulmonary, Critical Care, Allergy and Sleep Medicine (Drs. Doelken and Sahn), Medical University of South Carolina, Charleston, SC; Department of Medicine (Dr.Abreu), Knapp Medical Center, Weslaco, TX; and Division of Pulmonary and Critical Care Medicine (Dr. Mayo), Beth Israel Medical Center, New York, NY. Correspondence to: Paul H. Mayo, MD, FCCP, Division of Pulmonary and Critical Care Medicine 7D, Beth Israel Medical Center, First Ave and Sixteenth St, New York, NY 13; pmayo@chpnet.org (PEEP) cm H 2 O 2 s 8 / min (Ppeak) (Pplat) 25 ml 1 (Pliq) 342

3 (Validyne MP45 8 cm H 2 O Validyne Engineering; Northridge CA) (Hans Rudolph 37 Hans Rudolph Kansas City MO) Validyne MP (45 2).3 cm H 2 O Validyne Engineering (Gould Classic 65 Gould Instrument Systems Ilford UK) 8 (Transpac IV Abbott Critical Care Systems North Chicago IL) Pliq Ppeak Wv ( ) Cdyn,rs VT Ppeak Pplat (computer-fitted third-order polynomial equation).3 L (Cst,rs) [5] (P1) 1 VT / (Pplat-PEEPPEEPi) (Cdyn,rs) VT / (Ppeak-PEEP) (Rmax,rs) (Ppeak-Pplat) / / (Rinit,rs) (Ppeak-P1) / J / L 2 ( ) ( Rrs) (P1- (2 ) [6] Pplat) / PCO 2 [7 8] ( V) (Pryon SC-3 Pryon V =.26 s Corporation Menomonee Falls WI) PCO 2 3 min 4 VT P /cmh 2 O P1 Ppeak Pplat t /s 2s 5 ml ( 4 65 ml) 12 / min ( 1 17 / min) FIO 2.5 (.35.7) P(Aa)O 2.8 (VD) / VT (PaCO 2 - P CO 2 ) / PaCO 2 PCO 2 PCO 2 = PCO 2 VT (Ppeak-PEEP) CC / VT [9] 2 8 V /L.6 2 Ppeak 2 4 P /cm H 2 O 2 / t CHEST

4 1 (1) / / / kg / cm / ml 1 / / CHF, AIDS,, / / , AIDS,, / / CHF, 2 4 / / ,, / / ARF,, / / , / / CHF, COPD 7a,, 1 1 7b,, 8 8 / / , CHF, (1) CHF ARF t FIO 2.5 FIO 2 Wilcoxon P VD / VT.1.5 Cst, rs 2% Rmax, rs SPSS (Sigma Stat 2% Cdyn,rs 2. Chicago IL) 1% P(A-a)O 2 36 mm Hg 3 cmh 2 O P(A-a)O 2 36 mm Hg a 7b P VT ( ) ( ) Ppeak Pplat Cdyn,rs PEEP / min (.39) 7.1 (.39) 1. (1) VT / ml 557 (14.1) 561 (14.6).478 (1) / L s (.14) 1.14 (.12).159 (1) Ppeak / cm H 2 O 43.8 (4.56) 4.8 (3.52).8 (1) Pplat / cm H 2 O 2. (2.99) 17.8 (1.86).186 (1) Cdyn,rs / ml 14.5 (1.77) 15.2 (1.66).124 (1) cm H 2 O -1 PEEP / cm H 2 O (2) Pliq / cm H 2 O (2) (1) (2) t Wilcoxon Pliq (P =.8) 3 Pliq 5 Pliq 75 ml Pliq 1cmH 2 O 45 ml Pliq Pliq 344

5 4 5% VT VT (Wv) 95%CI Cdyn,rs Cst,rs Wv Rmax,rs Cdyn,rs Cdyn Cst,rs Rmax,rs 5% Rmax,rs Cst,rs Rmax,rs 95%CI Cst,rs 2% 5 ml (Est,pl,.5) 11.2 cm H 2 O ( 4 2.3) (Est,pl) 12.7 cm H 2 O ( 1.7) 4 Est,pl, cm H 2 O Est,pl 16.7 cm H 2 O 25 ml Pliq ml Cdyn,rs 1% cm H 2 O (β =.17) Cst,rs 2%.99 (β =.1) Rmax, 3 Rmax,rs Rinit,rs rs 2%.967 (β =.33) P(A- Rrs Cst,rs a)o 2 36 mm Hg.956 PEEPi (β =.44) VD / VT (P =.125) Wv (β=.15) (P =.11) 4 PaO 2 P(A-a)O 2 PaO 2 / FIO 2 VD / VT 2 95%CI [1] [11 13] Pliq / cm H 2 O /L Pliq FIO 2 PaO 2 P(A-a)O 2 PaCO 2 VD / VT CHEST

6 3 Rmax,rs / Rinit,rs / Rrs / cm H 2 O Cst,rs / ml cm H 2 O -1 PEEPi / PEEP / Wv / J L -1 cm H 2 O L -1 s -1 cm H 2 O L -1 s -1 L -1 s -1 (cm H 2 O) / / / / / 5 / / 5 1 / / 1 / / / a / 1 / b / 3 / / 1 / / / P.93 (1).57 (1).61 (1).22 (1).125 (2) / 1. (1).11 (1) (1) (2) t Wilcoxon (P =.125) Cst,rs [14] 1 8 Brandstetter [15] PaO 2 4 VT 5% [16 17] PaO 2 P(A-a)O 2 [2] PaO 2 P(A-a)O 2 [18 19] Perpina [17] Agusti [19] VD / 3 ml / kg VT [22] Pliq 2 21 Est,pl.5 Est, Cst, rs Cst,rs [23] pl 3 Cst,rs Pliq Cst,rs Cst,rs ( 346

7 ) Cdyn, rs Wv Cdyn,rs Wv Cdyn,rs Wv ( ) Cdyn,rs Rmax,rs PEEPi Wv Wv Cdyn,rs 2 Rmax,rs (Ppeak-Pplat) / 2 / Wv Pati [3] Wv PEEPi COPD [22] [24] Rmax,rs Rinit,rs Rrs Rinit,rs Rrs 4 PaO 2 / mm Hg P(A-a)O 2 /mmhg VD /VT a b / PEEPi P.37 (1).34 (1).35 (1) (1) t Rmax,rs Cst,rs CHEST

8 Cdyn,rs PEEPi ICU 4 Light RW, et al. Am Rev Respir Dis 1986;133: Bates JHT, et al. J Crit Care 1991;6: Behrakis PK, et al. J Appl Physiol 1983;55: Kochi T, et al. J Appl Physiol 1988;64: Lit LM, et al. Respir Care 24;49: Forbat AF, et al. Anesth Analg 198;59: Mattison LE, et al. Chest 1997;111: Godwin JE, et al. Ann Intern Med 199;98: Mayo PH, et al. Chest 24;125: Wv Wv Wv 14 Talmor M, et al. Surgery 1998;123: [25] 15 Brandstetter RD, et al. JAMA 1979;242: Wang JS, et al. Chest 1995;17: Perpina M, et al. Thorax 1983;38: Karetzky MS, et al. Respiration 1978;36:96 13 [26] Wv Light RW, et al. Am Rev Respir Dis 198;121: Lan R-S, et al. Ann Intern Med 1997;126: Dechman G, et al. Eur Respir J 1993;6: Yaylali YT, et al. South Med J 1997;9: ( ) 2 Brown NE, et al. Chest 1978;74: Pati AR, et al. Ind J Chest Dis Allied Sci 1983;25: Lichtenstein D, et al. Intensive Care Med 1999;25: Agusti AGN, et al. Am J Respir Crit Care Med 1997;156: 24 Pride NB, et al. Lung mechanics in disease. In: Macklem PT, et al, eds. Handbook of physiology. Bethesda, MD: American Physiological Society, 1986; Marini JJ, et al. Am Rev Respir Dis 1986;134: Estenne M, et al. Am J Med 1983;74: Chang-Ting L, et al. Panminerva Med 1991;33:86 92 CHEST 26;13:

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