Lung Mechanics

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L exin gton Pulm on ar y an d Cr itical Car e

Lexi ngt on, SC

Lun g M echanics & M echani cal V en tilation

By D onald R. Elton , M D , FCCP L exi n gton Pulm on ar y an d Cr i ti cal Car e W ho Car es?
Why do we car e about lung mechani cs dur i ng mechanical venti lat ion? We all should i f we want t o pr ovide adequat e vent ilat or y suppor t wi th a minimum of adver se effects. I t would be useful i f we could easily measur e lung compli ance, air way r esi st ance, funct ional r esidual capaci ty, and other pulmonar y funct ion par amet er s dur ing mechanical venti lat ion. Unfor t unat ely, it i s di fficult t o conduct for mal pulmonar y functi on t esti ng on cr it ically ill pati ent s who fr equent ly r equi r e high air way pr essur es and flows and may be par alyzed or other wise unable t o cooper at e wit h test ing. This paper will explor e t he t heor y and applicat ion of a few simple bedside maneuver s that anyone can per for m eit her wit h or wi thout pat ient cooper ati on t o assess lung mechani cs.

Com pli an ce

Compliance i s a measur ement of t he dist ensibi lit y of the lung. I t is expr essed as a change i n volume divi ded by a change in pr essur e. The standar d unit s of Lit er s/ cm H 20. The nor mal lung+thor ax compliance of an adult i s ar ound 0.1 L/ cm H 20. When the compli ance is low, mor e pr essur e wi ll be need to deli ver a gi ven volume of gas t o a pat ient . Disease st at es r esult ing i n low compliance i nclude t he Adult Respir ator y Di str ess Syndr ome (ARDS), pulmonar y edema, pneumonect omy, pleur al effusi on, pulmonar y fibr osi s, and pneumoni a among other s. Emphysema i s a t ypical cause of i ncr eased lung compliance.

Ai r w ay Resi stan ce

Resist ance is t he amount of pr essur e r equir ed to deliver a given flow of gas and i s expr essed i n t er ms of a change in pr essur e divided by flow. The standar d unit s of r esistance ar e cm H 20/ L/ second and the nor mal value for an adult is ar ound 0.5 - 1.5 cm H 20/ L/ sec while in st at es of disease this value may be 100.0 cm H 20/ L/ sec or hi gher . Ther e r eally ar en't any diseases char act er ized by decr eased ai r way r esist ance si nce nor mal values ar e so low but t her e ar e many di sease states that r esult i n i ncr eased air way r esi st ance i ncludi ng use of ar t ificial ai r ways, ast hma, emphysema wit h air way collapse, mucus plugging, vocal cor d par alysi s, and endobr onchial obst r uct ion eit her fr om tumor s or for eign bodies.

T im e Con stan t

The Time Const ant of the lung (TC) i s a concept bor r owed fr om electr i cal

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engi neer ing which descr ibes t he phenomenon wher eby a given per cent age of a passively exhaled br eat h of ai r will r equi r e a constant amount of t ime t o be exhaled r egar dless of the star ti ng volume given const ant lung mechanics. That 's quit e a mouth-full of a definit ion but consider what det er mi nes how long it t akes t o exhale a t idal br eat h passively. At the star t of exhalat ion, t he i nit i al flow of gas out of t he lung depends upon the dr i vi ng pr essur e (i.e. alveolar pr essur e - mout h pr essur e) and i t depends on the air way r esi st ance. For any given volume of gas, the alveolar pr essur e at t he st ar t of exhalati on i s only dependent upon the lung compli ance. M at hemat ically, the ti me constant i s defi ned as compli ance mult ipli ed by t he ai r way r esistance and t he r esult ing value has uni ts of seconds of t ime..

Ai r w ay Pr essur e & Alveolar Pr essur e

Air way pr essur e i s t he pr essur e measur ed at t he pat ient's ai r way dur ing mechanical venti lat ion. Air way pr essur e i s deter mined by t he sum of t he alveolar pr essur e and t he pr essur e r equi r ed t o deli ver flow acr oss t he air ways which i s deter mined by the ai r way r esist ance. Alveolar pr essur e is t he pr essur e i n the distensi ble par t s of the r espir ator y t r act and is deter mined by t he ti dal volume and t he lung/ chest compli ance. Air way pr essur e is equal to alveolar pr essur e when ther e is no flow occur r i ng. At the end of a mechanical i nspir ati on, flow t o t he dist al par t s of the lung cont inues even aft er inspir ator y flow fr om the venti lat or st ops as t ime is r equir ed for gas t o r each the per i pher y of the lung. To measur e alveolar pr essur e, one must measur e the air way pr essur e at a t ime when both pr essur es ar e equal, i.e. when t her e is no flow. M easur ing Compliance To measur e lung compli ance one must know t he deli ver ed t idal volume and must also know the change i n alveolar pr essur e t hat r esult s fr om t he addi ti on of that known t idal volume. We nor mally assume t hat alveolar and ai r way pr essur e st ar t out at at mospher i c (our zer o r efer ence) befor e an i nspi r at ion st ar t s. To equalize ai r way and alveolar pr essur es we only have to pr event exhalat ion aft er inspir ati on has ceased by ut ilizing an inspi r at or y hold maneuver . The actual calculati on i s t o di vi de t he deli ver ed t idal volume by the plat eau pr essur e wher e t he plateau pr essur e i s t he steady-st at e pr essur e measur ed dur i ng an inspir ator y hold maneuver . I f pr ecise measur ement is necessar y then the pr essur e should be the plateau pr essur e minus any end expir at or y pr essur e (or the pleur al pr essur e or AutoPEEP if it is available) and the volume should be ei ther measur ed at the air way it self or should be cor r ect ed for compr essible volume loss. I n most cases, appr oximat e values ar e adequat e for cli nical use so t he plateau pr essur e minus the end expi r at or y pr essur e is divided i nto the exhaled ti dal volume as measur ed by t he vent ilat or . This compliance measur ement is somet imes called t he stati c compli ance si nce i t is measur ed after an inspir ator y hold such t hat t her e is no gas flow dur ing it s measur ement .

M easur i n g Resistan ce

Air way r esi stance can be est imated by di vi di ng the differ ence between peak and plateau air way pr essur es by the mean i nspi r at or y flow r at e. Some vent ilat or s have an i nspi r at or y flow r at e set t ing such t hat you can r ead the cont r ol for an est imat e of deli ver ed flow r ate whi le ot her s give an inspir at or y t i me set t ing wher e you have t o divide the ti dal volume by t he inspir at or y ti me

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t o deter mine t he i nspi r at or y flow r at e. An alter nati ve way of followi ng air way r esi st ance is t o calculat e a nonsense par amet er known as t he dynamic compli ance . The dynami c compli ance is t he r esult of dividing t he deli ver ed t i dal volume by the peak air way pr essur e. Si nce peak ai r way pr essur e is det er mined by a combinati on of t he lung compliance, the air way r esi st ance, i nspir ator y flow r at e, and the t idal volume, t his value does not r eally give a quanti tat ive est imat e of ai r way r esistance i tself but can be used to detect changes i n t he air way r esi stance if all other fact or s ar e held constant. Thi s makes t he value useful for compar ing measur ement s on a single pati ent over a shor t per iod of ti me but it is t oo much t o ask t o expect t hat all of t he other var iables affecti ng peak air way pr essur e wi ll st ay t he same fr om day t o day or cer tainly fr om pati ent to pat ient . Because of t he limi tati ons of dynamic compli ance measur ement s, it makes mor e sense t o just follow the peak pr essur e t o plat eau pr essur e gr adient si nce i t r equir es less math and is just as useful (or useless) as t he dynamic compliance calculat ion. A thir d way t o est imat e air way r esi st ance can be used if the pat ient is exhaling passi vely. This met hod wor ks based on t he t ime constant. The pr act it i oner ti mes how long i t t akes for the pat ient t o exhale completely and t hen divides t his r esult by 3 t o est imat e the t ime constant. The lung compliance i s then measur ed and di vided i nt o t he t ime const ant to r esult in t he ai r way r esist ance t hus: Raw = Time Const ant / Clung

Auto PEEP

Aut o PEEP is t he popular name used t o descr ibe i ncr eased alveolar pr essur e caused by gas t r apping dur ing mechani cal vent ilati on. Gas t r apping occur s when ther e is i nadequate t ime t o exhale the mechanical t idal volume. Recall t hat t he ti me const ant det er mines the length of t ime needed for a passive exhalati on and t hat t he t ime const ant is t he pr oduct of air way r esistance and lung compli ance. The lower the compliance, the higher t he dr ivi ng pr essur e pushing gas out of t he lungs dur ing exhalati on; the lower t he r esistance, t he higher t he expir ator y flow r at e can be when dr i ven by the alveolar pr essur e. I f t he t ime constant is known (or can be est imated) t hen t he maximum mechanical r espi r at or y r at e that can be used befor e Aut o PEEP r esult s can be est imat ed. Consider that at least 3 ti me const ant s ar e r equi r ed t o exhale passively any volume of gas. The combi nat ion of i nspi r at or y and expir ator y t i me leads to a give r espir ator y r at e such that : Tot al Br eat h Time = I nsp t ime + Exp t ime Respir ator y Rat e = 60 / Total Br eat h Time M axi mum Rat e = 60 / (I nsp t ime + 3 x TC) A pat ient wi th a compliance of 0.05 L/ cm H 20 and an air way r esistance of 30 cm H 20/ L/ sec. Thi s would give a ti me const ant of 1.5 seconds. A complete exhalati on would t ake ar ound 4.5 seconds. I f inspir ator y t ime i s 1 second then t ot al br eath t ime is 5.5 seconds and t he maxi mum r espi r at or y r at e wit hout gas t r appi ng would be 11 br eat hs per mi nut e. When gas t r apping occur s, the funct ional r esi dual capacit y (FRC) is incr eased. As t he FRC incr eases, the

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alveolar pr essur e incr eases by an amount of pr essur e det er mi ned by t he pat ient's lung compliance. As t he FRC r i ses i n r elat ion to the tot al lung capacit y (TLC), t he lung compliance will decr ease. Thi s decr ease i n lung compli ance shor t ens t he t ime const ant for t he next br eat h and t hus shor t ens t he t ime r equir ed to exhale t he next br eat h and lessens the amount of t r appi ng t hat will occur wit h each subsequent br eat h unt il the t i me constant shor t ens enough t hat gas t r apping no longer occur s. When t his steady state i s r eached, the FRC is at it s maximum and t he aut o-PEEP is also at it s maximum. This fact gives us a way to measur e how much auto-PEEP exist s since we can ser i ally measur e exhaled t idal volumes and then int er r upt vent ilat ion (by t ur ning the r espir ator y r ate t o zer o for sever al seconds) and measur ing how much gas the pat ient exhales as t he pati ent exhales back to the FRC level t hat exist ed pr ior to vent ilat ion. I f we t ake the di ffer ence bet ween t he exhaled volume dur ing vent ilat ion and the exhaled volume aft er i nt er r upt ing vent ilat ion t hen we have t he amount of gas t hat was t r apped. I f we divide this volume by t he lung compliance we will have calculated the amount of aut o-PEEP applied to the alveoli dur ing vent ilat ion. Nor mally we ar e mor e i nter ested in avoiding aut o-PEEP t han i n measur ing it t hough ther e ar e many pat ient s i n whom i t cannot be avoided so it i s useful t o be able to quanti tat e it . Anot her way to detect aut o-PEEP is t o watch a pat ient 's chest movement and/ or br eath sounds dur ing exhalati on to see i f exhalat ion st ops pr ior to ini ti at ion of i nspi r at ion by t he vent ilat or . I f exhalati on doesn't fi nish t hen auto-PEEP i s occur r i ng. When exhaled t idal volumes cannot be measur ed (whi ch is seldom wit h moder n venti lat or s) t he level of auto-PEEP can be ver y r oughly esti mat ed by i nt er r upt ing exhalati on just pr i or t o i nit iati on of i nspir ati on and wat ching to see if t her e is a pr essur e incr ease at the air way as exhalati on cont inues into the cir cuit between the pat ient and the point of your i nt er r upt ion. Thi s i s not an accur ate measur ement since t he inter r upti on necessar i ly cut s exhalati on shor t er than it would nor mally be and because t he cir cuit volume dampens t he pr essur e measur ement but t hi s t echnique can be useful i f you ar e unable to use the mor e r eliable met hods out li ned above.

Refer ences

Shapir o BA, H ar r i son RA, Tr out CA: Clini cal Appli cati on of Respir ator y Car e, Year Book M edical Publi sher s, I nc, Chicago, 1982. Tobin, M J, Lodat o, RF: PEEP, Aut o-PEEP, and Water falls, Edi tor i al, Chest 1989, 96:449-51. Lai n, DC, Chaudhar y, BA et al: Aut o-PEEP and Pr oximal Air way Pr essur e, Need for clar i fi cati on, Edi tor i al, Chest 1990, 97:771. Duncan, SR, Ri zk, NW, Raffi n, TA: I nver se Rat io Vent ilat ion, PEEP in Di sguise?, Chest 1987, 92:390 -1. Wr i ght , J, Gong, H : "Aut o-PEEP": I nci dence, magni tude, and cont r ibuti ng fact or s, H ear t and Lung 1990, 19:352-7. H offman, RA, Er showsky, P, Kr ieger , P: Det er mi nati on of Aut o-PEEP Dur i ng Spont aneous and Contr olled Vent i lati on by M oni tor i ng Changes in EndExpir ator y Thor acic Gas Volume, Chest 1989, 96:613-6.

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2006 Don El ton Cont act Webmaster

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