Abstract
Objective
To examine the circulatory and respiratory effects of extrinsic positive end-expiratory pressure (PEEPe) in patients with chronic obstructive pulmonary disease (COPD) and dynamic hyperinflation during controlled mechanical ventilation.
Design
Different levels of PEEPe were applied randomly in mechanically ventilated patients with COPD and dynamic hyperinflation.
Setting
Respiratory Intensive Care Unit of a University Hospital.
Patients
9 patients with acute respiratory failure and dynamic hyperinflation due to acute exacerbation of COPD.
Interventions
PEEPe 35%, 58% and 86% of intrinsic PEEP (PEEPi) were applied.
Measurements and results
Using flow-directed pulmonary artery catheters hemodynamic measurements were obtained, while simultaneously lung volumes, airflows and airway pressures were recorded. In order to estimate alveolar pressures (Palv), rapid airway occlusions during passive expiration were also performed. At no level of PEEPe were significant changes in cardiac output, gas exchange variables, dead space, airways inflation resistances and respiratory system static end-inspiratory compliance observed. At high level of PEEPe central venous, mean pulmonary arterial and pulmonary capillary wedge pressures were increased significantly. All but one patient were flow-limited during passive expiration. PEEPe 86% of PEEPi caused a significant increase in end-expiratory lung volume and total PEEP. Iso-volume pressure-flow curves showed volume-dependence expiratory flow limitation in 2 patients, while in 8 patients volume-dependence of critical driving pressure (Palv-mouth pressure) that decreased flows was also observed.
Conclusions
The effects of PEEPe on iso-volume flow and hence on lung mechanics and hemodynamics, depend on many factors, such as airways resistances, lung volumes and airway characteristics, making the patient response to PEEPe unpredictable.
Article PDF
Similar content being viewed by others
References
Pepe PE, Marini JJ (1982) Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction. Am Rev Respir Dis 126:166–170
Murciano D, Aubier M, Bussi S, Derenne JR, Pariente R, Milic-Emili J (1982) Comparison of esophageal, tracheal, and mouth occlusion pressure in patients with chronic obstructive pulmonary disease during acute respiratory failure. Am Rev Respir Dis 126:837–841
Kimball WR, Leith DE, Robius AG (1982) Dynamic hyperinflation and ventilator dependence in chronic obstructive pulmonary disease. Am Rev Respir Dis 126:991–995
Fleury B, Murciano D, Talamo C, Aubier M, Pariente R, Milic-Emili J (1985) Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure. Am Rev Respir 132:822–827
Gottfried SB, Rossi A, Higgs BD, Calverly PM, Zocchi L, Bozic C, Milic-Emili J (1985) Noninvasive determination of respiratory system mechanics during mechanical ventilation for acute respiratory failure. Am Rev Respir Dis 131:414–420
Roussos C, Macklem PT (1982) The respiratory muscles. N Engl J Med 307:786–797
Smith TC, Marini JJ (1988) Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol 65:1488–1499
Petrof BJ, Legare P, Goldberg P, Milic-Emili J, Gottfried SB (1990) Continuous positive airway pressure reduces inspiratory work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 141:281–289
Rossi A, Brandolese R, Milic-Emili J, Gottfried SB (1990) The role of PEEP in patients with chronic obstructive pulmonary disease during assisted ventilation. Eur Respir J 3:818–822
Tuxen DV (1989) Detrimental effects of positive end-expiratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. Am Rev Respir Dis 140:5–9
Tuxen DV, Lane S (1987) The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 136:872–879
Hughes R, May AJ, Widdicombe J (1959) Stress relaxation in rabbits' lungs. J Physiol London 146:85–97
Rossi A, Gottfried SB, Zocchi L, Higgs ED, Lennox S, Calverly PMA, Begin P, Grassino A, Milic-Emili J (1985) Measurements of static complicance of total respiratory system in patients with acute respiratory failure during mechanical ventilation. Am Rev Respir Dis 131:672–677
Gottfried SB, Rossi A, Higgs BD, Zocchi L, Grassino A, Milic-Emili J (1985) Respiratory mechanics in mechanically ventilated patients with respiratory failure. J Appl Physiol 58:1849–1858
Bates JHT, Rossi A, Milic-Emili J (1985) Analysis of the behavior of the respiratory system with constant inspiratory flow. J Appl Physiol 58:1840–1848
Ludwig MS, Romero PV, Sly PD, Fredberg JJ, Bates JHT (1990) Interpretation of interrupter resistance after histamine-induced constriction in dogs. J Appl Physiol 68:1651–1656
Kochi T, Okubo S, Zin WA, Milic-Emili J (1988) Flow and volume dependence of pulmonary mechanics in anesthetized cats. J Appl Physiol 64:441–450
Shoemaker WC (1989) Shock states: pathophysiology, monitoring, outcome prediction, and therapy. In: Shoemaker, Ayres, Grenvik, Holbrook, Thompson (eds) Textbook of critical care. Saunders, Philadelphia, pp 977–993
Gay PC, Rodarte JR, Tayyab M, Hubmayr RD (1987) Evaluation of bronchodilator responsiveness in mechanically ventilated patients. Am Rev Respir Dis 136:880–885
Gay PC, Rodarte JR, Hubmayr RD (1989) The effects of positive end expiratory pressure on isovolume flow and dynamic hyperinflation in patients receiving mechanical ventilation. Am Rev Respir Dis 139:621–626
Hyatt RE (1961) The interrelationships of pressure, flow, and volume during various respiratory maneuvers in normal and emphysematous subjects. Am Rev Respir Dis 83:676–683
Hyatt RE (1986) Forced expiration. In: Macklem PT, Mead J (eds) Handbook of physiology: the respiratory system. Mechanics of breathing, vol III, part 1. American Physiological Society, pp 295–314
Dawson SV, Elliott EA (1977) Wave-speed limitation on expiratory flow—a unifying concept. J Appl Physiol 43:516–522
Marini J (1989) Should PEEP be used in airflow obstruction? Editorial. Am Rev Respir Dis 140:1–3
Margaria CE, Iscoe S, Pengelley LD, Conture J, Don H, Milic-Emili J (1973) Immediate ventilatory response to elastic loads and positive pressure in man. Respir Physiol 18:347369
Rossi A, Santos C, Roca J, Torres A, Felez MA, Rodriguez-Roisin R (1992) Effects of intrinsic PEEP on ventilation-perfusion mismatching in mechanically ventilated patients with acute on chronic airway obstruction. Am Rev Respir Dis (Abstract) 145:A76
Broseghini C, Brandolese R, Poggi R, Polese G, Manzin E, Milic-Emili J, Rossi A (1988) Respiratory mechanics during the first day of mechanical ventilation in patients with pulmonary edema and chronic airway obstruction. Am Rev Respir Dis 138:355–361
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Georgopulos, D., Giannouli, E. & Patakas, D. Effects of extrinsic positive end-expiratory pressure on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation. Intensive Care Med 19, 197–203 (1993). https://doi.org/10.1007/BF01694770
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF01694770