CHEST Peter Doelken, MD, FCCP; Ricardo Abreu, MD, FCCP; Steven A. Sahn, MD, FCCP; and Paul H. Mayo, MD, FCCP 8 7 1 (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 www.chestjournal.org.cn CHEST 27 6 4 6 341
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 (1 3 4 7a 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; e-mail: pmayo@chpnet.org (PEEP) cm H 2 O 2 s 8 / min (Ppeak) (Pplat) 25 ml 1 (Pliq) 342
(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 3 2 1-1 1 P1 Ppeak Pplat 1 2 3 4 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 www.chestjournal.org.cn CHEST 27 6 4 6 343
1 (1) / / / kg / cm / ml 1 / / 5 64 17 CHF, AIDS,, 1 75 2 / / 35 59 173, AIDS,, 1 5 3 / / 85 83 18 CHF, 2 4 / / 75 82 165,, 1 95 5 / / 9 46 142 ARF,, 1 2 6 / / 93 66 183, 1 95 7 / / 82 75 157 CHF, COPD 7a,, 1 1 7b,, 8 8 / / 84 45 15, CHF, 8 66.1 164 1 495 4.7 4.6 153 (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 8 1 2 2 1 7a 7b 2 1 2 P VT ( ) ( ) Ppeak Pplat Cdyn,rs PEEP / min -1 7.1 (.39) 7.1 (.39) 1. (1) VT / ml 557 (14.1) 561 (14.6).478 (1) / L s -1 1.15 (.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 5.4 2.9.125 (2) Pliq / cm H 2 O 11.1-6.6.8 (2) (1) (2) t Wilcoxon Pliq (P =.8) 3 Pliq 5 Pliq 75 ml Pliq 1cmH 2 O 45 ml Pliq Pliq 344
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,.5 27.2 cm H 2 O Est,pl 16.7 cm H 2 O 25 ml Pliq 25 1 25 ml Cdyn,rs 1%.893 9.5 cm H 2 O (β =.17) Cst,rs 2%.99 (β =.1) Rmax, 3 Rmax,rs Rinit,rs -2-1 1 2 rs 2%.967 (β =.33) P(A- Rrs Cst,rs a)o 2 36 mm Hg.956 PEEPi (β =.44) VD / VT.1.985 (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 -2 3 1 2 /L Pliq FIO 2 PaO 2 P(A-a)O 2 PaCO 2 VD / VT www.chestjournal.org.cn CHEST 27 6 4 6 345
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) 1 14.7 14. 11.2 8.7 3.5 5.3 33.3 31.5 6 / / 3.97 2.89 2 1.2 1. 8.5 8. 1.7 1.9 5.1 47.9 / / 2.64 2.45 3 8. 8.8 5.4 5.3 2.6 3.6 37.6 34. / 5 / 5 2.35 2.33 4 14.6 14.8 9.1 9. 5.5 5.8 22. 24.5 4 / 5 1 / 5 3.66 3.1 5 7.9 8.4 5.2 5.8 2.7 2.5 39.1 34.3 1 / 1 / 2.47 2.54 6 1.4 8.8 6.8 6.4 3.6 2.4 66.3 61.9 / / 2.2 1.98 7a 23.3 26.3 15.6 17.6 7.6 8.8 34.8 4.9 15 / 1 / 5.6 4.49 7b 27.9 29.6 18.6 19.5 9.2 1.1 37.4 37.1 12 / 3 / 4.74 3.91 8 22.3 18.1 15. 12.8 7.3 5.3 53.6 45.8 1 / 1 / 3.65 3.34 15.5 15.4 1.6 1.3 4.9 5.1 41.6 39.8 4.3 / 1.1 1.8 / 1.1 3.42 2.99 2.4 2.6 1.6 1.7.9 1. 4.4 3.7.35.27 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
) 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 1 11 92 224 234.41.31 2 78 15 251 199.49.48 3 81 117 41 359.38.48 4 17 146 159 187.39.37 5 81 84 129 121.5.57 6 13 115 365 343.57.65 7a 71 75 143 149.55.54 7b 88 85 138 138.55.61 8 92 97 227 229.48.48 96 12 226 217.48.5 9.9 7.3 33.2 28.4.24.37 / PEEPi P.37 (1).34 (1).35 (1) (1) t Rmax,rs Cst,rs www.chestjournal.org.cn CHEST 27 6 4 6 347
Cdyn,rs PEEPi ICU 4 Light RW, et al. Am Rev Respir Dis 1986;133:658 661 5 Bates JHT, et al. J Crit Care 1991;6:227 238 6 Behrakis PK, et al. J Appl Physiol 1983;55:185 192 7 Kochi T, et al. J Appl Physiol 1988;64:2636 2646 8 Lit LM, et al. Respir Care 24;49:122 128 9 Forbat AF, et al. Anesth Analg 198;59:488 493 1 Mattison LE, et al. Chest 1997;111:118 123 11 Godwin JE, et al. Ann Intern Med 199;98:113 1132 12 Mayo PH, et al. Chest 24;125:159 162 Wv Wv Wv 14 Talmor M, et al. Surgery 1998;123:137 143 [25] 15 Brandstetter RD, et al. JAMA 1979;242:16 161 16 Wang JS, et al. Chest 1995;17:161 1614 17 Perpina M, et al. Thorax 1983;38:747 75 18 Karetzky MS, et al. Respiration 1978;36:96 13 [26] Wv 125 129 2 Light RW, et al. Am Rev Respir Dis 198;121:799 84 21 Lan R-S, et al. Ann Intern Med 1997;126:768 774 22 Dechman G, et al. Eur Respir J 1993;6:219 224 23 Yaylali YT, et al. South Med J 1997;9:1156 1158 ( ) 2 Brown NE, et al. Chest 1978;74:54 542 3 Pati AR, et al. Ind J Chest Dis Allied Sci 1983;25:12 126 13 Lichtenstein D, et al. Intensive Care Med 1999;25:955 958 19 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;659 692 25 Marini JJ, et al. Am Rev Respir Dis 1986;134:92 99 26 Estenne M, et al. Am J Med 1983;74:813 819 1 Chang-Ting L, et al. Panminerva Med 1991;33:86 92 CHEST 26;13:1354 1361 348