Limited predictability of maximal muscular pressure using the difference between peak airway pressure and positive end-expiratory pressure during proportional assist ventilation (PAV)

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Abstract

Background: If the proportional assist ventilation (PAV) level is known, muscular effort can be estimated from the difference between peak airway pressure and positive end-expiratory pressure (PEEP) (∆P) during PAV. We conjectured that deducing muscle pressure from ∆P may be an interesting method to set PAV, and tested this hypothesis using the oesophageal pressure time product calculation. Methods: Eleven mechanically ventilated patients with oesophageal pressure monitoring under PAV were enrolled. Patients were randomly assigned to seven assist levels (20-80%, PAV20 means 20% PAV gain) for 15 min. Maximal muscular pressure calculated from oesophageal pressure (Pmus, oes) and from ∆P (Pmus, aw) and inspiratory pressure time product derived from oesophageal pressure (PTPoes) and from ∆P (PTPaw) were determined from the last minute of each level. Pmus, oes and PTPoes with consideration of PEEPi were expressed as Pmus, oes, PEEPi and PTPoes, PEEPi, respectively. Pressure time product was expressed as per minute (PTPoes, PTPoes, PEEPi, PTPaw) and per breath (PTPoes, br, PTPoes, PEEPi, br, PTPaw, br). Results: PAV significantly reduced the breathing effort of patients with increasing PAV gain (PTPoes 214.3 ± 80.0 at PAV20 vs. 83.7 ± 49.3 cmH2O•s/min at PAV80, PTPoes, PEEPi 277.3 ± 96.4 at PAV20 vs. 121.4 ± 71.6 cmH2O•s/min at PAV80, p < 0.0001). Pmus, aw overestimates Pmus, oes for low-gain PAV and underestimates Pmus, oes for moderate-gain to high-gain PAV. An optimal Pmus, aw could be achieved in 91% of cases with PAV60. When the PAV gain was adjusted to Pmus, aw of 5-10 cmH2O, there was a 93% probability of PTPoes <224 cmH2O•s/min and 88% probability of PTPoes, PEEPi < 255 cmH2O•s/min. Conclusion: Deducing maximal muscular pressure from ∆P during PAV has limited accuracy. The extrapolated pressure time product from ∆P is usually less than the pressure time product calculated from oesophageal pressure tracing. However, when the PAV gain was adjusted to Pmus, aw of 5-10 cmH2O, there was a 90% probability of PTPoes and PTPoes, PEEPi within acceptable ranges. This information should be considered when applying ∆P to set PAV under various gains.

Original languageEnglish
Article number382
JournalCritical Care
Volume20
Issue number1
DOIs
Publication statusPublished - 2016 Nov 27

All Science Journal Classification (ASJC) codes

  • Critical Care and Intensive Care Medicine

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