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WO2024251630A1 - Détermination rapide de la pression transpulmonaire chez un patient relié à un appareil respiratoire - Google Patents

Détermination rapide de la pression transpulmonaire chez un patient relié à un appareil respiratoire Download PDF

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WO2024251630A1
WO2024251630A1 PCT/EP2024/065137 EP2024065137W WO2024251630A1 WO 2024251630 A1 WO2024251630 A1 WO 2024251630A1 EP 2024065137 W EP2024065137 W EP 2024065137W WO 2024251630 A1 WO2024251630 A1 WO 2024251630A1
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peep
pressure
lung
level
breathing
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Ola Stenqvist
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Lung Barometry Sweden AB
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M16/00—Devices for influencing the respiratory system of patients by gas treatment, e.g. ventilators; Tracheal tubes
    • A61M16/021—Devices for influencing the respiratory system of patients by gas treatment, e.g. ventilators; Tracheal tubes operated by electrical means
    • A61M16/022—Control means therefor
    • A61M16/024—Control means therefor including calculation means, e.g. using a processor
    • A61M16/026—Control means therefor including calculation means, e.g. using a processor specially adapted for predicting, e.g. for determining an information representative of a flow limitation during a ventilation cycle by using a root square technique or a regression analysis
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/08—Measuring devices for evaluating the respiratory organs
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M16/00—Devices for influencing the respiratory system of patients by gas treatment, e.g. ventilators; Tracheal tubes
    • A61M16/0003—Accessories therefor, e.g. sensors, vibrators, negative pressure
    • A61M2016/0027—Accessories therefor, e.g. sensors, vibrators, negative pressure pressure meter
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M16/00—Devices for influencing the respiratory system of patients by gas treatment, e.g. ventilators; Tracheal tubes
    • A61M16/0003—Accessories therefor, e.g. sensors, vibrators, negative pressure
    • A61M2016/003—Accessories therefor, e.g. sensors, vibrators, negative pressure with a flowmeter
    • A61M2016/0033—Accessories therefor, e.g. sensors, vibrators, negative pressure with a flowmeter electrical
    • A61M2016/0036—Accessories therefor, e.g. sensors, vibrators, negative pressure with a flowmeter electrical in the breathing tube and used in both inspiratory and expiratory phase

Definitions

  • TITLE Rapid determination of transpulmonary pressure in a patient connected to a breathing apparatus
  • the mechanical properties of the total respiratory system was hitherto determined by the combined effect of stiffness of the lungs and the stiffness of the chest wall/diaphragm working in series.
  • the lung is a compliant unit within another compliant unit, namely the chest wall and the diaphragm.
  • knowledge of the stiffness of the chest wall in relation to the stiffness of the lung is of outmost importance.
  • the risk of inducing damage to the sensitive lung tissue by the ventilator treatment is increasing when the lung is very stiff and the chest wall/diaphragm is very soft, where most of the airway pressure generated by the ventilator during inspiration acts solely on the lung, i.e. a high transpulmonary pressure is present. Very little of the pressure applied by the ventilator to the patient is transmitted to the surrounding chest wall and diaphragm.
  • the present disclosure is about such advantageous improvement, allowing for improved accuracy and patient safety, amongst other advantages.
  • embodiments of the present invention preferably seek to mitigate, alleviate or eliminate one or more deficiencies, disadvantages or issues in the art, such as the above-identified, singly or in any combination by providing a breathing apparatus, computer program, and method according to the appended patent claims.
  • EitP End inspiratory transpulmonary pressure
  • a breathing apparatus having a processing unit configured to determinate an End inspiratory transpulmonary pressure (EitP) in a method of stepwise increased PEEP levels wherein said determination is performed within a number of breathing cycles after an increased PEEP level, and wherein said number of breathing cycles is less than 5.
  • EitP End inspiratory transpulmonary pressure
  • a time of said determination is less than 40 seconds, such as less than 20 seconds.
  • said number of breathing cycles is less than 4, said number of breathing cycles is less than 3, said number of breathing cycles is 2, or said number of breathing cycles is 1 .
  • said determination is provided or performed during mechanical ventilation of a patient in volume control mode of a breathing device such as a ventilator or anesthesia machine.
  • said breathing device is programmed to deliver a double baseline tidal volume before PEEP is increased during ensuing expiration.
  • said determination is provided or performed during mechanical ventilation of a patient in pressure control mode of a breathing device such as a ventilator or anesthesia machine.
  • said breathing device is programmed to deliver a tidal volume with the sum of the baseline driving pressure and the increase in PEEP.
  • said method includes providing a tidal volume with a driving pressure at physiological levels such with a plateau pressure below 45 cm H2O, wherein said driving pressure is more than 1 ,3 times the driving pressure at baseline PEEP before increasing PEEP to the new level (stepwise increase of PEEP).
  • said driving pressure is equal to or more than 1 ,5 times the driving pressure at baseline PEEP before increasing PEEP to the new level (stepwise increase of PEEP).
  • said driving pressure is equal to or more than 2,0 times the driving pressure at baseline PEEP before increasing PEEP to the new level (stepwise increase of PEEP).
  • said determination is provided or is performed at regular intervals during mechanical ventilation of a patient, such as once every 30 minutes or once every hour.
  • said method is a single stepwise increase of said PEEP level, or a multiple stepwise increase of said PEEP levels.
  • EitP End inspiratory transpulmonary pressure
  • a breathing apparatus such as the breathing apparatus referenced to herein above, having a processing unit configured to determinate an End inspiratory transpulmonary pressure (EitP) in a method of stepwise increased PEEP levels, wherein said EitP is estimated at a highest PEEP level of said method based on previous PEEP steps, including estimation of lung elastance EL at said highest PEEP level.
  • EitP End inspiratory transpulmonary pressure
  • an end-inspiratory transpulmonary P/V point at the highest PEEP level is estimated subtracting APPL obtained by linear extrapolation of the APPL of the at least one lower PEEP level from the end-inspiratory airway pressure at the highest PEEP level.
  • end-inspiratory transpulmonary pressure at the highest PEEP level is estimated by extrapolating a APPL from a APPL at lower PEEP levels
  • end-inspiratory transpulmonary P/V point at the highest PEEP level is estimated subtracting APPL obtained by linear extrapolation of the APPL of the lower PEEP levels from the end-inspiratory airway pressure at the highest PEEP level.
  • the determined EitP is useable as parameter for controlling the breathing apparatus.
  • a clinical decision system may be based on the determined EitP Being able to provide the determined EitP value is hugely advantageous as it is made very patient friendly (no continued high levels of clinically acceptable needed) as well due to its determination speed very computational friendly, cost efficient and clinically acceptable as almost no waiting time is needed. As the determination can be repeated more often (each determination maneuver takes less time) patient care can be improved as e.g. clinically interesting changes in EitP can be determined quickly.
  • Figs. 1 and 2 illustrate a measurement procedure
  • Figs. 3 and 4 illustrate another measurement procedure
  • Fig. 5 is an illustration is provided of a change in offset between Vti and Vte when PEEP is increased
  • Fig. 6 is an illustration is provided of a best-fit linear and 3rd degree polynomial line of cumulative AEELV;
  • Fig. 7 are illustrative CT scans
  • Fig. 8 is an illustration of Breath-by-breath build-up of a new PEEP/EELV equilibrium
  • Fig. 9 is an illustration of absolute lung volume and Quasistatic pressures
  • Fig. 10 is an illustration of a basic PEEP step procedure
  • Fig. 11 is a P/V diagram illustrating a PEEP increase procedure
  • Fig. 12 is an illustration of an extended two-step PEEP procedure
  • Fig. 13 is a PA/ diagram of such an extended procedure
  • Fig. 14 is a P/V curve
  • Fig. 15 are various PTP/V curves
  • Fig. 16 is another PTP/V curve illustrating extrapolation of APPL
  • Fig. 17 is yet another plot of transpulmonary pressure plotted vs volume
  • Fig. 18 illustrates a comparison of two PTP/V curves
  • Fig. 19 is a P/V curve
  • Fig. 20 are two different PTP/V curves
  • Fig. 21 is an illustration of various distributions
  • Fig. 22 is yet another PTP/V curve
  • Fig. 23 are various PTP/V curves
  • Fig. 24 is yet another PTP/V curve
  • Fig. 25 is yet another PTP/V curve
  • Fig. 26 are two different PTP/V curves
  • Fig. 27 is a PA/ diagram
  • Fig. 28 is a PEEP / Impedance diagram
  • Fig. 29 is a PTP / V diagram comparison and overview
  • Fig. 30 is a schematic illustration of a breathing apparatus described herein.
  • Fig. 31 is a flowchart of a method described herein.
  • End inspiratory transpulmonary pressure (EitP) is performed within a number of breathing cycles after an increased PEEP level, and wherein said number of breathing cycles is less than 5.
  • Fig. 1 illustrates a One-step measurement procedure in volume control mode.
  • the upper panels and lower panels show inspiratory and expiratory tidal volume (VTi, VTe) and PEEP and end-inspiratory airway plateau pressure (Pee, Pei) as line and bar diagrams.
  • the vertical lines indicate that the last inspiration before PEEP is increased starts from baseline PEEP level and that the first inspiration after the PEEP increase starts from the new PEEP level.
  • Fig. 2 Left panel: Cumulative AEELV (ALSO DENOTED DEELV) breath-by-breath shows that EELV slowly increases and reaches a new plateau level after 14-15 breaths.
  • Right panel PA/ diagram of one-step procedure. Red arrows: tidal airway P/V curves at 10 and 20 cmH2O of PEEP. Blue line: Lung P/V curve between PEEP levels.
  • the driving pressure of the last inspiration before the PEEP increase is the sum of the set driving pressure at baseline and the selected increase in PEEP. This causes a much larger last tidal inspiration followed by an expiration that ends at the selected PEEP level (fig. 3, 4).
  • a One-step measurement procedure is preformed and provided in pressure control (or alternatively in pressure support mode).
  • Upper panels and lower panels show inspiratory and expiratory tidal volume (VTi, VTe) and PEEP and end-inspiratory airway plateau pressure (Pee, Pei) as line and bar diagrams.
  • the vertical lines indicate that the driving pressure of the last inspiration before PEEP is the sum of the driving pressure set at baseline, 16 cmH20 and the selected increase in PEEP, 10 cmH20, a total driving pressure of 26 cmH20. This results in a tidal volume of around 700 ml, i.e. around 300 ml higher than baseline tidal volumes.
  • Fig. 4 the Left panel illustrates Cumulative AEELV breath-by-breath shows that the increase in EELV seems to be complete after 2-3 breaths.
  • the almost linear increase in EELV after the 2-3 first breaths is a result of a change in off-set between VTi and VTe when PEEP is increased (fig. 5).
  • the Right panel in Fig. 4 illustrates in PA/ diagram a one-step procedure.
  • the "Red” "arrows” show the tidal airway P/V curves at 10 and 20 cmH20 of PEEP.
  • the "Blue” line shows the Lung P/V curve between PEEP levels.
  • FIG. 5 an illustration is provided of a change in offset between Vti and Vte when PEEP is increased analysed as Vti - Vte before and after PEEP up. Breaths number one and two after PEEP up are excluded. Offset during baseline is zero, while mean offset of breaths 3 - 15 after PEEP up is 9 ml. The almost linear increase in AEELV during breaths 3 -15 is 112 ml and is a result of change of offset. The true AEELV thus is probably the sum of AEELV of breaths 1 and 2, 531 ml.
  • Fig. 6 an illustration is provided of a best-fit linear and 3rd degree polynomial line of cumulative AEELV from the second breath after increasing PEEP and onwards in PC and VC. This supports the notion that the full AEELV is reached in two breaths in pressure control/support ventilation due to the large pre- PEEP up tidal volume (fig. 6).
  • Fig. 7 a representative CT scan is shown that is obtained in one dog at end-expiration for each experimental step.
  • a 3rd degree polynomial best-fit curve in VC has an r2 of 0.99 while in PC, such a best-fit curve show a non-plausible form and only reaches a r2 of 0.94. This further supports that the increase of EELV after the two first breaths in PC is a result of a change in offset between VTi and VTeafter increasing PEEP.
  • the ventilator is preferably configured and/or programmed to deliver a double baseline tidal volume before PEEP is increased during the ensuing expiration.
  • the ventilator In pressure control ventilation, the ventilator preferably configured and/or programmed programmed to deliver a tidal volume with the sum of the baseline driving pressure and the increase in PEEP.
  • the time for expiration after the large inspiration is preferably at least doubled to allow for a completion of AEELV build up in as few breaths as possible.
  • the driving pressure is for instance equal to or more than 1 ,5 times the driving pressure at baseline PEEP before increasing PEEP to the new level (stepwise increase of PEEP).
  • said driving pressure is equal to or more than 2,0 times the driving pressure at baseline PEEP before increasing PEEP to the new level (stepwise increase of PEEP).
  • Fig. 8 a Breath-by-breath build-up of a new PEEP/EELV equilibrium is illustrated in model. Note, that transpulmonary pressure at end-inspiration of a tidal volume of 500 ml (in red square) is equal to transpulmonary pressure at end-expiration at a PEEP of 10 cmH20 and a EELV of 500 ml, i.e. an increase in EELV of 500 ml above FRC (the figures in a "red” square).
  • Fig. 9 is an illustration of absolute lung volume and Quasistatic pressures.
  • the Upper panel in Fig. 9 illustrates an Original registration (L. Chen of Brochard group, Toronto) of airway, and esophageal pressure at 5 and 15 cmH20 of PEEP of patient in Chen et al. Am J Resp Crit Care Med 2020;201 (2): 178- 87 (1).
  • the lower panel of Fig. 9 shows whole lines inserted to eliminate cardiac pressure variations to enhance analysis.
  • a method 350 including determining 365 of End inspiratory transpulmonary pressure (EitP) in a method of stepwise increased PEEP level(s). The determination is performed within a number of breathing cycles 370 after increasing a PEEP level 360. The number of breathing cycles is less than 5.
  • a breathing apparatus 300 having a processing unit 310 configured to determinate an End inspiratory transpulmonary pressure (EitP) in a method of stepwise increased PEEP levels.
  • the processing unit is configured to execute a software for this.
  • the software is performing the method disclosed in the previous paragraph and elsewhere herein.
  • the software is stored on a computer readable medium of/accessible by the breathing apparatus 300 or other suitable hardware, e.g. e personal digital communication device. Determination may in examples be made remote from the breathing apparatus, but based on input from sensors of the breathing apparatus known in the art. The determination is performed within a number of breathing cycles after an increased PEEP level, and said number of breathing cycles is less than 5.
  • the calculation of a lung PA/ curve during a PEEP trial is preferably performed using end- expiratory and end-inspiratory airway pressure and measurements of AEELV by the cumulative expiratory tidal volume method, i.e. without using esophageal pressure data. Besides being simpler, this improves precision of measurements, as precision of esophageal pressure measurements is hampered by their dependency on the calibration procedure, the Baydur maneuver, as esophageal pressure is not representative of mean pleural pressure. The Baydur maneuver is regarded as acceptable if the APES during the maneuver is within a range of 0.8 - 1 .2 of the APAW caused by the compression of the thorax, which means that APES precision is very low.
  • AEELV is preferably determined directly and not indirectly as the difference of EELV measurements by nitrogen washin/washout (N2 Wi/Wo) between two PEEP levels.
  • the N2 Wi/Wo method has typically a variability in measurements of ⁇ 10 %.
  • the EELV at the low PEEP can be between 1620 and 1980 ml and EELV at the high PEEP level can be between 1890 and 2310 ml.
  • AEELV measured by washin/washout can be between 690 ml and - 90 ml, which is an unacceptable span.
  • determination of AEELV by the cumulative expiratory tidal volume difference method is very precise as the inspiratory tidal volume varies less than 1 % and can be regarded as constant during a PEEP step maneuver.
  • the method determines AEELV directly as the cumulative difference in only expiratory tidal volume.
  • AEELV up and down is determined and the procedure is finalized by setting the tidal volume to the mean of AEELV up and down.
  • Fig. 10 a basic PEEP step procedure is illustrated.
  • Roman digits are referring to the three different parts of the measurement procedure.
  • the arabic digits are identifying end-inspiratory and end- expiratory PA/ points where transpulmonary pressure can be determined. Italics indicate where transpulmonary pressure only is estimated.
  • Fig. 11 a PA/ diagram is provided illustrating of the PEEP increase basic procedure.
  • "Red” arrows tidal airway P/V curves.
  • "Blue” arrows tidal transpulmonary P/V curves.
  • Dashed “blue” line estimated curve based on the assumption that chest wall elastance is almost constant when increasing PEEP.
  • PEEP is increased in two steps from baseline level and then lowered again from the highest PEEP level to the first PEEP level above baseline. AEELV up and down for the highest PEEP step are determined and the tidal volume is set equal to mean AEELV 2. Then PEEP is lowered to baseline PEEP level and AEELV up and down for the first PEEP step is determined and the procedure finalized by setting the tidal volume equal to mean AEELV 1 .
  • Fig. 13 P/V diagram of an extended procedure.
  • "Red” lower arrows” tidal airway P/V curves.
  • “Blue” upper arrows tidal transpulmonary P/V curves.
  • Dashed "blue” arrow/line estimated curve based on the assumption that chest wall elastance is almost constant when increasing PEEP.
  • Step 1 The lung P/V curve is obtained by plotting the end-expiratory transpulmonary pressure (PAWEE) versus the end-expiratory lung volume at each PEEP level (see Fig. 14).
  • PAWEE end-expiratory transpulmonary pressure
  • Fig. 14 When lung elastance is determined as the difference in end-expiratory airway pressure divided by the difference in volume between two PEEP levels, this is the true lung elastance, as at end-expiration at a steady state PEEP/EELV equilibrium, the static airway pressure measured is equal to static transpulmonary pressure (see Fig. 6).
  • This means that lung elastance is determined directly in contrast to the conventional method, where lung elastance is determined indirectly as the difference between respiratory system elastance and chest wall elastance.
  • the direct method for determining lung elastance (APAWEE/AEELV ) is extremely precise, as the end-expiratory airway pressure is maintained by the ventilator within mmH20 of set value and reflects the mean transpulmonary
  • a lung P/V curve can be obtained by plotting the end-expiratory airway pressure vs cumulative end-expiratory lung volume.
  • Step 2 As the end-expiratory and end-inspiratory lung P/V curves coincide and forms a common single lung P/V curve, the end-inspiratory transpulmonary pressure at each PEEP level can be determined by solving the best-fit equation for the lung P/V curve for the end-inspiratory lung volume at each PEEP level ( see Fig. 15).
  • the end-inspiratory transpulmonary pressure, PTPei is determined by solving the equation for the lung P/V curve at the end-expiratory lung volume at each PEEP level.
  • Black arrows point at the end-inspiratory pressure level.
  • Step 3 The end-inspiratory transpulmonary pressure at the highest PEEP level (16 cmH20) cannot be determined exactly as the lung P/V curve is non-linear and the chest wall elastance increases slightly PEEP step by PEEP step. Instead, the end-inspiratory transpulmonary pressure at the highest PEEP level can be estimated by extrapolating the DPPL (AP PI, change in pleural pressure) from the DPPL at the four lower PEEP levels (see Fig. 16).
  • AP PI change in pleural pressure
  • the end-inspiratory transpulmonary P/V point at the highest PEEP level is estimated subtracting DPPL obtained by linear extrapolation of the DPPL of the four lower PEEP levels from the end-inspiratory airway pressure at the highest PEEP level.
  • the extrapolated APPL is 7.0 cmH20 and as the PAWEI is 25.7 cmH20, the PTPEI is 18.7 cmH20.
  • the left panel in Fig 18 shows a Comparison with lung P/V curve where the increase in end- expiratory transpulmonary pressure is calculated as AEELV x EL, where EL is determined conventionally as (APAW - APES)/VT.
  • EL is determined conventionally as (APAW - APES)/VT.
  • the tidal lung P/V curves are aligned on a single lung P/V curve gray dotted line), but the end-expiratory transpulmonary P/V points are not coinciding with the end-expiratory airway P/V points, and the whole lung P/V curve, as a consequence, right shifted in relation to the end-expiratory airway P/V curve.
  • Fig 18 shows a comparison where tidal lung P/V curves start from end- expiratory airway P/V points, where the tidal lung P/V curves are right shifted from the end-expiratory airway P/V curve. Consequently, tidal inspiratory lung P/V curves do not coincide with the end- expiratory airway P/V curve.
  • Tidal P/V curves are shown including: airway: “red” (lowest) arrows, lung (transpulmonary): “blue” (mid) arrows, chest wall (pleura): “green” (upper) arrows. Dashed “green” line: end-expiratory chest wall P/V curve (APPLEE/AEELV).
  • PEEP has been increased so AEELV has increased to a level equal to the tidal volume at baseline PEEP (500 ml), as AEELV is determined by the size of the PEEP step (10 cmH20) and lung elastance (20 cmH2O/L).
  • End-expiratory transpulmonary pressure increase calculated as AEELV x EL, is 10 cmH20, and this means that end-expiratory transpulmonary pressure at the high PEEP level is equal to the end-inspiratory transpulmonary pressure of the tidal volume at baseline PEEP, which means that the transpulmonary driving pressure of a tidal volume equal to AEELV, is equal to APEEP. Consequently, transpulmonary pressure at a certain lung volume level is independent of mode of inflation: tidal or PEEP inflation and the tidal pleural pressure changes are equal to PAWEI L OPEEP - PAWEEHIPEEP- Regional lung P/V curves
  • the lung P/V curve passes through the end-expiratory airway P/V points and show a decreasing lung elastance when PEEP is increased in the responder and an increasing lung elastance in the non-responder (see Fig.20).
  • lung P/V curves are illustrated for a PEEP responder (left panel) and PEEP non-responder (right panel).
  • Step 1 The lung P/V curve is obtained by plotting the end-expiratory transpulmonary pressure (PAWEE) versus the end-expiratory lung volume at each PEEP level (see Fig. 22).
  • PAWEE end-expiratory transpulmonary pressure
  • the direct method for determining lung elastance is extremely precise, as the end-expiratory airway pressure is maintained by the ventilator within mmH 2 0 of set value and reflects the mean transpulmonary pressure of the whole lung.
  • a lung P/V curve can be obtained by plotting the end-expiratory airway pressure vs cumulative end-expiratory lung volume.
  • Step 2 As the end-expiratory and end-inspiratory lung P/V curves coincide and forms a common single lung P/V curve, the end-inspiratory transpulmonary pressure at each PEEP level can be determined by solving the best-fit equation for the lung P/V curve for the end-inspiratory lung volume at each PEEP level (see Fig. 23).
  • the end-inspiratory transpulmonary pressure, PTPEI is determined by solving the eguation for the lung P/V curve at the end-expiratory lung volume at each PEEP level.
  • Blue arrows tidal lung P/V curves. Black arrows point at the end-inspiratory pressure level.
  • Step 3 The end-inspiratory transpulmonary pressure at the highest PEEP level (16 cmH 2 0) cannot be determined exactly as the lung P/V curve is non-linear and the chest wall elastance increases slightly PEEP step by PEEP step. Instead, the end-inspiratory transpulmonary pressure at the highest PEEP level can be estimated by extrapolating the APPL from the APPL at the four lower PEEP levels (see Fig. 24).
  • the end-inspiratory transpulmonary P/V point at the highest PEEP level is estimated subtracting APPL obtained by linear extrapolation of the APPL of the four lower PEEP levels from the end-inspiratory airway pressure at the highest PEEP level.
  • the extrapolated APPL is 7.0 cmH 2 0 and as the PA WEI is 25.7 cmH 2 0, the PTPEI is 18.7 cmH 2 0.
  • Fig. 26 The lung P/V curve calculated as described in figures 5-8, where the expiratory lung curve is indicated by a red dotted line and the tidal lung P/V curves indicated by dark blue arrows.
  • FIG. 26 Left panel: Comparison with lung P/V curve where the increase in end- expiratory transpulmonary pressure is calculated as AEELV x EL, where EL is determined conventionally as (APAW - APES). /VT. Note that the tidal lung P/V curves (grey arrows) are aligned on a single lung P/V curve gray dotted line), but the end-expiratory transpulmonary P/V points are not coinciding with the end-expiratory airway P/V points, and the whole lung P/V curve, as a conseguence, right shifted in relation to the end-expiratory airway P/V curve.
  • FIG. 27 Tidal P/V curves: airway: red arrows, lung (transpulmonary): blue arrows, chest wall (pleura): green arrows. Dashed green line: end-expiratory chest wall P/V curve (APPLEE/AEELV).
  • AEELV has increased to a level egual to the tidal volume at baseline PEEP (500 ml), as AEELV is determined by the size of the PEEP step (10 cmH 2 O) and lung elastance (20 cmF O/L).
  • End-expiratory transpulmonary pressure increase calculated as AEELV x EL, is 10 cmF O, and this means that end-expiratory transpulmonary pressure at the high PEEP level is egual to the end- inspiratory transpulmonary pressure of the tidal volume at baseline PEEP, which means that the transpulmonary driving pressure of a tidal volume egual to AEELV, is egual to APEEP.
  • transpulmonary pressure at a certain lung volume level is independent of mode of inflation: tidal or PEEP inflation and the tidal pleural pressure changes are equal to PAWEI L OPEEP - PAWEEHIPEEP- Regional lung P/V curves
  • the ratio of tidal impedance variation (AZ) to tidal volume (ml) is determined for each PEEP level.
  • the tidal volume is constant, 420 ml during the whole PEEP trial.
  • the regional impedance change (AZ) related to tidal ventilation is registered from the regional EIT curves.
  • the percentage AZ of each region at each PEEP level is calculated.
  • the regional tidal volume for each PEEP level is calculated as percent AZ times tidal volume (ml) (Table 1).
  • the regional change in end-expiratory lung volume was calculated as the regional AZ/AEELV divided by AZ/ml determined as the tidal impedance change divided by the tidal volume (Table 2).
  • FIG. 29 Lung P/V curves in a PEEP responder. Upper panels: Whole lung. Lower panels: Lung P/V curves in ventral and dorsal lung. End-expiratory (open circles) and end-inspiratory (closed circles) transpulmonary P/V points. Dashed vertical lines connect end-expiratory P/V points and whole vertical lines connect end-inspiratory transpulmonary P/V points in the whole lung and ventral and dorsal lung separately, as static pressures are the same everywhere

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  • Measurement Of The Respiration, Hearing Ability, Form, And Blood Characteristics Of Living Organisms (AREA)

Abstract

En particulier, l'invention concerne un procédé de détermination de la pression transpulmonaire inspiratoire finale (EitP) dans un procédé à niveau de pression expiratoire positive augmenté pas à pas, ladite détermination étant effectuée dans un certain nombre de cycles de respiration après un niveau de pression expiratoire positive accru, et ledit nombre de cycles de respiration étant inférieur à 5.
PCT/EP2024/065137 2023-06-08 2024-06-02 Détermination rapide de la pression transpulmonaire chez un patient relié à un appareil respiratoire Pending WO2024251630A1 (fr)

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WO2011157855A1 (fr) 2010-06-19 2011-12-22 M Stenqvist Ab Système et procédé de détermination de la pression transpulmonaire chez un patient connecté à un appareil respiratoire
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US20190374733A1 (en) * 2017-02-22 2019-12-12 Koninklijke Philips N.V. Automatic peep selection for mechanical ventilation
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WO2011157855A1 (fr) 2010-06-19 2011-12-22 M Stenqvist Ab Système et procédé de détermination de la pression transpulmonaire chez un patient connecté à un appareil respiratoire
US20130174846A1 (en) * 2010-06-19 2013-07-11 The Lung Barometry Sweden Ab C/O Stenqvist System and method for determination of transpulmonary pressure in a patient connected to a breathing apparatus
WO2016189069A1 (fr) 2015-05-25 2016-12-01 The Lung Barometry Sweden AB Procédé, système et logiciel de ventilation de protection
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