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Work of Breathing During Lung-Protective Ventilation in Patients With Acute Lung Injury and Acute Respiratory Distress Syndrome: A Comparison Between Volume and Pressure-Regulated Breathing Modes

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Abstract:

BACKGROUND: Pressure-control ventilation (PCV) and pressure-regulated volume-control (PRVC) ventilation are used during lung-protective ventilation because the high, variable, peak inspiratory flow rate (VI) may reduce patient work of breathing (WOB) more than the fixed VI of volume-control ventilation (VCV). Patient-triggered breaths during PCV and PRVC may result in excessive tidal volume (VT) delivery unless the inspiratory pressure is reduced, which in turn may decrease the peak VI. We tested whether PCV and PRVC reduce WOB better than VCV with a high, fixed peak VI (75 L/min) while also maintaining a low VT target. METHODS: Fourteen nonconsecutive patients with acute lung injury or acute respiratory distress syndrome were studied prospectively, using a random presentation of ventilator modes in a crossover, repeated-measures design. A target VT of 6.4 ± 0.5 mL/kg was set during VCV and PRVC. During PCV the inspiratory pressure was set to achieve the same VT. WOB and other variables were measured with a pulmonary mechanics monitor (Bicore CP-100). RESULTS: There was a nonsignificant trend toward higher WOB (in J/L) during PCV (1.27 ± 0.58 J/L) and PRVC (1.35 ± 0.60 J/L), compared to VCV (1.09 ± 0.59 J/L). While mean VT was not statistically different between modes, in 40% of patients, VT markedly exceeded the lung-protective ventilation target during PRVC and PCV. CONCLUSIONS: During lung-protective ventilation, PCV and PRVC offer no advantage in reducing WOB, compared to VCV with a high flow rate, and in some patients did not allow control of VT to be as precise.

Keywords: ACUTE LUNG INJURY; ACUTE RESPIRATORY DISTRESS SYNDROME; ASYNCHRONY; LUNG-PROTECTIVE VENTILATION; MECHANICAL VENTILATION; TIDAL VOLUME; WORK OF BREATHING

Document Type: Research Article

Affiliations: 1: Critical Care Division, Department of Anesthesia, Respiratory Care Services, San Francisco General Hospital, NH:GA-2, 1001 Potrero Avenue, San Francisco CA 94110;, Email: richkallet@earthlink.net 2: Department of Surgery, University of California, San Francisco, at San Francisco General Hospital, San Francisco, California 3: Department of Anesthesia, University of California, San Francisco, at Moffitt-Long Hospital, San Francisco, California

Publication date: December 1, 2005

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