[Foundations of Volumetric capnography : Principles of monitoring of metabolism and hemodynamics]. / Grundlagen der Volumetrischen Kapnographie : Prinzipien der Überwachung von Stoffwechsel und Hämodynamik.

Capnography is the graphical representation of the carbon dioxide (CO2) concentration in expired air. Using this monitoring procedure, the kinetics of CO2 of mechanically ventilated patients can be assessed in a noninvasive way and in real time. This article highlights the importance, particularly of volumetric capnography (VCap), for clinical monitoring of mechanically ventilated patients. The procedure provides important information on the breathing, ventilation, metabolism and hemodynamics of patients.

[Volumetric capnography for analysis and optimization of ventilation and gas exchange]. / Volumetrische Kapnographie zur Analyse und Optimierung von Ventilation und Gasaustausch.

Capnography as the graphical representation of the expiratory carbon dioxide (CO2) concentration, is an essential component of monitoring of every ventilated patient, in addition to pulse oximetry. Capnography demonstrates the kinetics of CO2 in a noninvasive way and in real time. In the daily routine anesthesia, it mainly serves for identification of the correct intubation and adaptation of the respiratory minute volume to be applied; however, capnography can also provide much more far-reaching and clinically particularly valuable information, especially in the form of volumetric capnography (VCap) that is not yet so widely clinically available. These include monitoring and optimization of ventilation and assessment of gas exchange. This article presents parameters for making decisions at the bedside, which could previously only be obtained by extensive, more invasive, nonautomated procedures.

Monitoring of tidal ventilation by electrical impedance tomography in anaesthetised horses.

BACKGROUND: Electrical impedance tomography (EIT) is a method to measure regional impedance changes within the thorax. The total tidal impedance variation has been used to measure changes in tidal volumes in pigs, dogs and men. OBJECTIVES: To assess the ability of EIT to quantify changes in tidal volume in anaesthetised mechanically ventilated horses. STUDY DESIGN: In vivo experimental study. METHODS: Six horses (mean ± s.d.: age 11.5 ± 7.5 years and body weight 491 ± 40 kg) were anaesthetised using isoflurane in oxygen. The lungs were mechanically ventilated using a volume-controlled mode. With an end-tidal carbon dioxide tension in the physiological range, and a set tidal volume (VTvent ) of 11-16 mL/kg (baseline volume), EIT data and VT measured by conventional spirometry were collected over 1 min. Thereafter, VTvent was changed in 1 L steps until reaching 10 L. After, VTvent was reduced to 1 L below the baseline volume and then further reduced in 1 L steps until 4 L. On each VT step data were recorded for 1 min after allowing 1 min of stabilisation. Impedance changes within the predefined two lung regions of interest (EITROI ) and the whole image (EITthorax ) were calculated. Linear regression analysis was used to assess the relationship between spirometry data and EITROI and EITthorax for individual horses and pooled data. RESULTS: Both EITROI and EITthorax significantly predicted spirometry data for individual horses with R2 ranging from 0.937 to 0.999 and from 0.954 to 0.997 respectively. This was similar for pooled data from all six horses with EITROI (R2 = 0.799; P<0.001) and EITthorax (R2 = 0.841; P<0.001). MAIN LIMITATIONS: The method was only tested in healthy mechanically ventilated horses. CONCLUSIONS: The EIT can be used to quantify changes in tidal volume.

Detection of thoracic vascular structures by electrical impedance tomography: a systematic assessment of prominence peak analysis of impedance changes.

OBJECTIVE: Electrical impedance tomography (EIT) is a non-invasive and radiation-free bedside monitoring technology, primarily used to monitor lung function. First experimental data shows that the descending aorta can be detected at different thoracic heights and might allow the assessment of central hemodynamics, i.e. stroke volume and pulse transit time. APPROACH: First, the feasibility of localizing small non-conductive objects within a saline phantom model was evaluated. Second, this result was utilized for the detection of the aorta by EIT in ten anesthetized pigs with comparison to thoracic computer tomography (CT). Two EIT belts were placed at different thoracic positions and a bolus of hypertonic saline (10 ml, 20%) was administered into the ascending aorta while EIT data were recorded. EIT images were reconstructed using the GREIT model, based on the individual's thoracic contours. The resulting EIT images were analyzed pixel by pixel to identify the aortic pixel, in which the bolus caused the highest transient impedance peak in time. MAIN RESULTS: In the phantom, small objects could be located at each position with a maximal deviation of 0.71 cm. In vivo, no significant differences between the aorta position measured by EIT and the anatomical aorta location were obtained for both measurement planes if the search was restricted to the dorsal thoracic region of interest (ROIs). SIGNIFICANCE: It is possible to detect the descending aorta at different thoracic levels by EIT using an intra-aortic bolus of hypertonic saline. No significant differences in the position of the descending aorta on EIT images compared to CT images were obtained for both EIT belts.

Electrical impedance tomography for non-invasive assessment of stroke volume variation in health and experimental lung injury.

BACKGROUND: Functional imaging by thoracic electrical impedance tomography (EIT) is a non-invasive approach to continuously assess central stroke volume variation (SVV) for guiding fluid therapy. The early available data were from healthy lungs without injury-related changes in thoracic impedance as a potentially influencing factor. The aim of this study was to evaluate SVV measured by EIT (SVVEIT) against SVV from pulse contour analysis (SVVPC) in an experimental animal model of acute lung injury at different lung volumes. METHODS: We conducted a randomized controlled trial in 30 anaesthetized domestic pigs. SVVEIT was calculated automatically analysing heart-lung interactions in a set of pixels representing the aorta. Each initial analysis was performed automatically and unsupervised using predefined frequency domain algorithms that had not previously been used in the study population. After baseline measurements in normal lung conditions, lung injury was induced either by repeated broncho-alveolar lavage (n=15) or by intravenous administration of oleic acid (n=15) and SVVEIT was remeasured. RESULTS: The protocol was completed in 28 animals. A total of 123 pairs of SVV measurements were acquired. Correlation coefficients (r) between SVVEIT and SVVPC were 0.77 in healthy lungs, 0.84 after broncho-alveolar lavage, and 0.48 after lung injury from oleic acid. CONCLUSIONS: EIT provides automated calculation of a dynamic preload index of fluid responsiveness (SVVEIT) that is non-invasively derived from a central haemodynamic signal. However, alterations in thoracic impedance induced by lung injury influence this method.

Perioperative assessment of regional ventilation during changing body positions and ventilation conditions by electrical impedance tomography.

BACKGROUND: Lung-protective ventilation is claimed to be beneficial not only in critically ill patients, but also in pulmonary healthy patients undergoing general anaesthesia. We report the use of electrical impedance tomography for assessing regional changes in ventilation, during both spontaneous breathing and mechanical ventilation, in patients undergoing robot-assisted radical prostatectomy. METHODS: We performed electrical impedance tomography measurements in 39 patients before induction of anaesthesia in the sitting (M1) and supine position (M2), after the start of mechanical ventilation (M3), during capnoperitoneum and Trendelenburg positioning (M4), and finally, in the supine position after release of capnoperitoneum (M5). To quantify regional changes in lung ventilation, we calculated the centre of ventilation and 'silent spaces' in the ventral and dorsal lung regions that did not show major impedance changes. RESULTS: Compared with the awake supine position [2.3% (2.3)], anaesthesia and mechanical ventilation induced a significant increase in silent spaces in the dorsal dependent lung [9.2% (6.3); P<0.05]. Capnoperitoneum and the Trendelenburg position led to a significant increase in such spaces [11.5% (8.9)]. Silent space in the ventral lung remained constant throughout anaesthesia. CONCLUSION: Electrical impedance tomography was able to identify and quantify on a breath-by-breath basis circumscribed areas, so-called silent spaces, within healthy lungs that received little or no ventilation during general anaesthesia, capnoperitoneum, and different body positions. As these silent spaces are suggestive of atelectasis on the one hand and overdistension on the other, they might become useful to guide individualized protective ventilation strategies to mitigate the side-effects of anaesthesia and surgery on the lungs.

Hyperoxia affects the regional pulmonary ventilation/perfusion ratio: an electrical impedance tomography study.

BACKGROUND: The way in which hyperoxia affects pulmonary ventilation and perfusion is not fully understood. We investigated how an increase in oxygen partial pressure in healthy young volunteers affects pulmonary ventilation and perfusion measured by thoracic electrical impedance tomography (EIT). METHODS: Twelve semi-supine healthy male volunteers aged 21-36 years were studied while breathing room air and air-oxygen mixtures (FiO2) that resulted in predetermined transcutaneous oxygen partial pressures (tcPO2) of 20, 40 and 60 kPa. The magnitude of ventilation (ΔZv) and perfusion (ΔZQ)-related changes in cyclic impedance variations, were determined using an EIT prototype equipped with 32 electrodes around the thorax. Regional changes in ventral and dorsal right lung ventilation (V) and perfusion (Q) were estimated, and V/Q ratios calculated. RESULTS: There were no significant changes in ΔZv with increasing tcPO2 levels. ΔZQ in the dorsal lung increased with increasing tcPO2 (P = 0.01), whereas no such change was seen in the ventral lung. There was a simultaneous decrease in V/Q ratio in the dorsal region during hyperoxia (P = 0.04). Two subjects did not reach a tcPO2 of 60 kPa despite breathing 100% oxygen. CONCLUSION: These results indicate that breathing increased concentrations of oxygen induces pulmonary vasodilatation in the dorsal lung even at small increases in FiO2. Ventilation remains unchanged. Local mismatch of ventilation and perfusion occurs in young healthy men, and the change in ventilation/perfusion ratio can be determined non-invasively by EIT.

Capnography reflects ventilation/perfusion distribution in a model of acute lung injury.

BACKGROUND: Changes in the shape of the capnogram may reflect changes in lung physiology. We studied the effect of different ventilation/perfusion ratios (V/Q) induced by positive end-expiratory pressures (PEEP) and lung recruitment on phase III slope (S(III)) of volumetric capnograms. METHODS: Seven lung-lavaged pigs received volume control ventilation at tidal volumes of 6 ml/kg. After a lung recruitment maneuver, open-lung PEEP (OL-PEEP) was defined at 2 cmH(2)O above the PEEP at the onset of lung collapse as identified by the maximum respiratory compliance during a decremental PEEP trial. Thereafter, six distinct PEEP levels either at OL-PEEP, 4 cmH(2)O above or below this level were applied in a random order, either with or without a prior lung recruitment maneuver. Ventilation-perfusion distribution (using multiple inert gas elimination technique), hemodynamics, blood gases and volumetric capnography data were recorded at the end of each condition (minute 40). RESULTS: S (III) showed the lowest value whenever lung recruitment and OL-PEEP were jointly applied and was associated with the lowest dispersion of ventilation and perfusion (Disp(R-E)), the lowest ratio of alveolar dead space to alveolar tidal volume (VD(alv)/VT(alv)) and the lowest difference between arterial and end-tidal pCO(2) (Pa-ETCO(2)). Spearman's rank correlations between S(III) and Disp(R-E) showed a ρ=0.85 with 95% CI for ρ (Fisher's Z-transformation) of 0.74-0.91, P<0.0001. CONCLUSION: In this experimental model of lung injury, changes in the phase III slope of the capnograms were directly correlated with the degree of ventilation/perfusion dispersion.

Effect of pulmonary perfusion on the slopes of single-breath test of CO2.

The objective of this study was to evaluate the effects of lung perfusion on the slopes of phases II (S(II)) and III (S(III)) of a single-breath test of CO(2) (SBT-CO(2)). Fourteen patients submitted to cardiac surgery were studied during weaning from cardiopulmonary bypass (CPB). Pump flow was decreased in 20% steps, from 100% (total CPB = 2.5 l.min(-1).m(-2)) to 0%. This maneuver resulted in a progressive and opposite increase in pulmonary blood flow (PBF) while maintaining ventilator settings constant. SBT-CO(2), respiratory, and hemodynamic variables remained unchanged before and after CPB, reflecting a constant condition at those stages. S(III) was similar before and after CPB (19.6 +/- 2.8 and 18.7 +/- 2.1 mmHg/l, respectively). S(III) was lowest during 20% PBF (8.6 +/- 1.9 mmHg/l) and increased in proportion to PBF until exit from CPB (15.6 +/- 2.2 mmHg/l; P < 0.05). Similarly, S(II) and the CO(2) area under the curve increased from 163 +/- 41 mmHg/l and 4.7 +/- 0.6 ml, respectively, at 20% PBF to 313 +/- 32 mmHg/l and 7.9 +/- 0.6 ml (P < 0.05) at CPB end. When S(II) and S(III) were normalized by the mean percent expired CO(2), they remained unchanged during the protocol. In summary, the changes in PBF affect the slopes of the SBT-CO(2). Normalizing S(II) and S(III) eliminated the effect of changes in the magnitude of PBF on the shape of the SBT-CO(2) curve.

[Effects of the alveolar recruitment manoeuver and PEEP on arterial oxygenation in anesthetized obese patients]. / Efectos de la maniobra de reclutamiento alveolar y la PEEP sobre la oxigenación arterial en pacientes obesos anestesiados.

BACKGROUND: Diminished functional residual capacity and pulmonary collapse during general anesthesia lead to alterations in respiratory mechanics and gas exchange. Such phenomena are more pronounced in obese patients. We recently demonstrated the beneficial effects of the alveolar recruitment strategy on oxygenation in anesthetized patients of normal body mass index (BMI). The aim of the present study was to evaluate whether obese patients also benefit from the alveolar recruitment strategy and to determine the level of positive end-expiratory pressure (PEEP) that prevents recollapse in obese patients. METHODS: Three groups of 30 patients each were studied: patients with normal BMI (control group) and obese patients to whom we applied PEEP at 5 and 10 cm H2O (obese-5 and obese-10 groups, respectively) after the recruitment maneuver. We studied respiratory mechanics (respiratory distensibility, airway pressures and flow volume) and arterial oxygenation (PaO2) before and after the recruitment. RESULTS: PaO2 at baseline was higher in the control group (174 +/- 44 mm Hg) than in either the obese-5 or obese-10 group (108 +/- 24 and 114 +/- 22 mm Hg, respectively, p < 0.001). Oxygenation improved in all groups after recruitment (p < 0.001), and PaO2 in the obese-10 group was similar to that of the control group (218 +/- 25 mm Hg and 259 +/- 80 mm Hg, respectively, p > 0.05). Oxygenation in the obese-5 group, however, was worse (153 +/- 41 mm Hg) than that of either of the other groups (p < 0.001). CONCLUSIONS: We conclude that the alveolar recruitment strategy was effective for increasing PaO2 in anesthetized patients, regardless of body mass. The oxygenation of obese patients receiving the higher level of PEEP was similar to that of non-obese patients.

[Treatment of anesthesia-induced atelactasis]. / Prävention und Therapie anästhesiebedingter Atelektasen.

During general anaesthesia even healthy lungs tend to collapse. Thus, up to 20% of previously functional lung tissue may be lost for gas exchange. It should be advantageous to treat this pathologic condition. After explaining the clinical problem of lung collapse, the concept of opening these lungs and keeping them open will be discussed. Some results of the first randomized clinical trials on intraoperative lung recruitment will be presented. Finally, a systematic description of all treatment steps tries to provide the anaesthesiologist with a useful practical guide for applying the "alveolar recruitment strategy" in their daily care of patients undergoing general anaesthesia.

Regional pressure volume curves by electrical impedance tomography in a model of acute lung injury.

OBJECTIVE: A new noninvasive method, electrical impedance tomography (EIT), was used to make pressure-impedance (PI) curves in a lung lavage model of acute lung injury in pigs. The lower inflection point (LIP) and the upper deflection point (UDP) were determined from these curves and from the traditional pressure-volume (PV) curves to determine whether the PI curves resemble the traditional PV curves. Furthermore, regional differences in the mentioned determinants were investigated. DESIGN: Prospective, experimental study. SETTING: Animal research laboratory. INTERVENTIONS: In nine anesthetized pigs, repeated lung lavage was performed until a Pao2 <80 torr was reached. Thereafter, an inspiratory PV curve was made using a constant flow of oxygen. During the intervention, EIT measurements were performed. MEASUREMENTS AND MAIN RESULTS: In this study, the LIP(EIT) was within 2 cm H2O of the LIP(PV). Furthermore, it was possible to visualize regional PI curves by EIT. No significant difference was found between the LIP(PV) (21.3+/-3.0 cm H2O) and the LIP(EIT) of the total lung (21.5+/-3.0 cm H2O) or the anterior parts of the lung (21.5+/-2.9 cm H2O). A significantly higher LIP (29.5+/-4.9 cm H2O) was found in the posterior parts of the lung. A UDP(PV) could be found in three animals only, whereas in all animals a UDP(EIT) could be determined from the anterior part of the lung. CONCLUSIONS: Using EIT, determination of LIP and UDP from the regional PI curves is possible. The obtained information from the regional PI curves may help in understanding alveolar recruitment. The use of this new bedside technique for clinical decision making remains to be examined.

Monitoring of recruitment and derecruitment by electrical impedance tomography in a model of acute lung injury.

OBJECTIVE: To evaluate a noninvasive system for obtaining information about alveolar recruitment and derecruitment in a model of acute lung injury. DESIGN: Prospective experimental study. SETTING: Animal research laboratory. SUBJECTS: Nine anesthetized pigs. INTERVENTIONS: Electrical impedance tomography measurements were performed. Electrical impedance tomography is an imaging technique that can register the ventilation-induced impedance changes in different parts of the lung. In nine anesthetized pigs, repeated lung lavages were performed until a PaO2 of <80 mm Hg was reached. Thereafter, the lungs were recruited according to two different recruitment protocols: the open lung approach and the open lung concept. Five time points for measurements were chosen: healthy (reference), lavage (atelectasis), recruitment, derecruitment, and maintain recruited (final). MEASUREMENTS AND MAIN RESULTS: After lavage, there was a significant increase in the impedance ratio, defined as the ventilation-induced impedance changes of the anterior part of the lung divided by that of the posterior part (from 1.75 +/- 0.63 to 4.51 +/- 2.22; p < .05). The impedance ratio decreased significantly after performing the recruitment protocol (from 4.51 +/- 2.22 to 1.18 +/- 0.51). During both recruitment procedures, a steep increase in baseline impedance change was seen. Furthermore, during derecruitment, a decrease in the slope in baseline impedance change was seen in the posterior part of the lung, whereas the anterior part showed no change. CONCLUSION: Electrical impedance tomography is a technique that can show impedance changes resembling recruitment and derecruitment of alveoli in the anterior and posterior parts of the lung. Therefore, electrical impedance tomography may help in determining the optimal mechanical ventilation in a patient with acute lung injury.

'Alveolar recruitment strategy' improves arterial oxygenation during general anaesthesia.

Abnormalities in gas exchange during general anaesthesia are caused partly by atelectasis. Inspiratory pressures of approximately 40 cm H2O are required to fully re-expand healthy but collapsed alveoli. However, without PEEP these re-expanded alveoli tend to collapse again. We hypothesized that an initial increase in pressure would open collapsed alveoli; if this inspiratory recruitment is combined with sufficient end-expiratory pressure, alveoli will remain open during general anaesthesia. We tested the effect of an 'alveolar recruitment strategy' on arterial oxygenation and lung mechanics in a prospective, controlled study of 30 ASA II or III patients aged more than 60 yr allocated to one of three groups. Group ZEEP received no PEEP. The second group received an initial control period without PEEP, and then PEEP 5 cm H2O was applied. The third group received an increase in PEEP and tidal volumes until a PEEP of 15 cm H2O and a tidal volume of 18 ml kg-1 or a peak inspiratory pressure of 40 cm H2O was reached. PEEP 5 cm H2O was then maintained. There was a significant increase in median PaO2 values obtained at baseline (20.4 kPa) and those obtained after the recruitment manoeuvre (24.4 kPa) at 40 min. This latter value was also significantly higher than PaO2 measured in the PEEP (16.2 kPa) and ZEEP (18.7 kPa) groups. Application of PEEP also had a significant effect on oxygenation; no such intra-group difference was observed in the ZEEP group. No complications occurred. We conclude that during general anaesthesia, the alveolar recruitment strategy was an efficient way to improve arterial oxygenation.

Exogenous surfactant preserves lung function and reduces alveolar Evans blue dye influx in a rat model of ventilation-induced lung injury.

BACKGROUND: Changes in pulmonary edema infiltration and surfactant after intermittent positive pressure ventilation with high peak inspiratory lung volumes have been well described. To further elucidate the role of surfactant changes, the authors tested the effect of different doses of exogenous surfactant preceding high peak inspiratory lung volumes on lung function and lung permeability. METHODS: Five groups of Sprague-Dawley rats (n = 6 per group) were subjected to 20 min of high peak inspiratory lung volumes. Before high peak inspiratory lung volumes, four of these groups received intratracheal administration of saline or 50, 100, or 200 mg/kg body weight surfactant; one group received no intratracheal administration. Gas exchange was measured during mechanical ventilation. A sixth group served as nontreated, nonventilated controls. After death, all lungs were excised, and static pressure-volume curves and total lung volume at a transpulmonary pressure of 5 cm H2O were recorded. The Gruenwald index and the steepest part of the compliance curve (Cmax) were calculated. A bronchoalveolar lavage was performed; surfactant small and large aggregate total phosphorus and minimal surface tension were measured. In a second experiment in five groups of rats (n = 6 per group), lung permeability for Evans blue dye was measured. Before 20 min of high peak inspiratory lung volumes, three groups received intratracheal administration of 100, 200, or 400 mg/ kg body weight surfactant; one group received no intratracheal administration. A fifth group served as nontreated, nonventilated controls. RESULTS: Exogenous surfactant at a dose of 200 mg/kg preserved total lung volume at a pressure of 5 cm H2O, maximum compliance, the Gruenwald Index, and oxygenation after 20 min of mechanical ventilation. The most active surfactant was recovered in the group that received 200 mg/kg surfactant, and this dose reduced minimal surface tension of bronchoalveolar lavage to control values. Alveolar influx of Evans blue dye was reduced in the groups that received 200 and 400 mg/kg exogenous surfactant. CONCLUSIONS: Exogenous surfactant preceding high peak inspiratory lung volumes prevents impairment of oxygenation, lung mechanics, and minimal surface tension of bronchoalveolar lavage fluid and reduces alveolar influx of Evans blue dye. These data indicate that surfactant has a beneficial effect on ventilation-induced lung injury.

Surfactant impairment after mechanical ventilation with large alveolar surface area changes and effects of positive end-expiratory pressure.

We have assessed the effects of overinflation on surfactant function and composition in rats undergoing ventilation for 20 min with 100% oxygen at a peak inspiratory pressure of 45 cm H2O, with or without PEEP 10 cm H2O (groups 45/10 and 45/0, respectively). Mean tidal volumes were 48.4 (SEM 0.3) ml kg-1 in group 45/0 and 18.3 (0.1) ml kg-1 in group 45/10. Arterial oxygenation in group 45/0 was reduced after 20 min compared with group 45/10 (305 (71) vs 564 (10) mm Hg); maximal compliance of the P-V curve was decreased (2.09 (0.13) vs 4.16 (0.35) ml cm H2O-1 kg-1); total lung volume at a transpulmonary pressure of 5 cm H2O was reduced (6.5 (1.0) vs 18.8 (1.4) ml kg-1) and the Gruenwald index was less (0.22 (0.02) vs 0.40 (0.05)). Bronchoalveolar lavage fluid from the group of animals who underwent ventilation without PEEP had a greater protein concentration (2.18 (0.11) vs 0.76 (0.22) mg ml-1) and a greater minimal surface tension (37.2 (6.3) vs 24.5 (2.8) mN m-1) than in those who underwent ventilation with PEEP. Group 45/0 had an increase in non-active to active total phosphorus compared with nonventilated controls (0.90 (0.16) vs 0.30 (0.07)). We conclude that ventilation in healthy rats with peak inspiratory pressures of 45 cm H2O without PEEP for 20 min caused severe impairment of pulmonary surfactant composition and function which can be prevented by the use of PEEP 10 cm H2O.

A successful computerized protocol for clinical management of pressure control inverse ratio ventilation in ARDS patients.

We have developed a computerized protocol that provides a systematic approach for management of pressure control-inverse ratio ventilation (PCIRV). The protocols were used for 1,466 h in ten around-the-clock PCIRV evaluations on seven patients with severe adult respiratory distress syndrome (ARDS). Patient therapy was controlled by protocol 95 percent of the time (1,396 of 1,466 h) and 90 percent of the protocol instructions (1,937 of 2,158) were followed by the clinical staff. Of the 221 protocol instructions, 88 (39 percent) not followed were due to invalid PEEPi measurements. Compared with preceding values during CPPV, the expired minute ventilation was reduced by 27 percent during PCIRV while maintaining a pH that was not clinically different (mean difference in pH = 0.02). There was no difference in the PaO2, PEEPi, or the FIO2 between PCIRV and CPPV. The PEEP setting was reduced by 33 percent from 9 +/- 0.05 to 6 +/- 0.6 and the I:E ratio increased from 0.64 +/- 0.04 to 2.3 +/- 0.10. Peak airway pressure was reduced by 24 percent (from 59 +/- 1.5 to 45 +/- 0.6) and mean airway pressure increased by 27 percent (from 22 +/- 0.8 to 28 +/- 0.6) in PCIRV. Right atrial and pulmonary artery pressures were higher and cardiac output lower in PCIRV but blood pressure was unchanged. The success of this protocol has demonstrated the feasibility of using PEEPi as a primary control variable for oxygenation. This computerized PCIRV protocol should make the future use of PCIRV less mystifying, simpler, and more systematic.

In vivo demonstration of the Haldane effect during extracorporeal gas exchange.

During the extracorporeal support (LFPPV-ECCO2R) of 11 patients suffering from severe lung failure (ARDS), we consistently noticed a higher arterial than mixed-venous PCO2 in blood samples drawn at the same time. Two explanations are possible: a) the Haldane effect (HE), b) CO2 from lung tissue metabolism. In order to distinguish changes in PCO2 due to the HE from those due to tissue CO2 production, CO2 content (CCO2) was calculated. The results were compared to animal experiments with hyperoxic apnea, after which arterial and mixed-venous samples were drawn simultaneously. All blood gas samples were analyzed for pH, PCO2, PO2, and O2-saturation, from which CCO2 was calculated. In both groups, PaCO2 was 2.15 mmHg (2.7 mmHg respectively) higher at a lower CaCO2 (-2.87 ml/l, -14.9 ml/l). Oxygen saturation increased by 8.1% in the human group and 17.8% in the animal group. A significant relationship was found between changes in PCO2 and changes in O2-saturation. This is a demonstration of the Haldane effect.