Influences of assisted breathing and mechanical ventilator settings on tidal volume and alveolar pressures in acute respiratory distress syndrome: a bench study

To evaluate the influences of respiratory muscle efforts and respiratory rate setting in the ventilator on tidal volume and alveolar distending pressures at end inspiration and expiration in volume-controlled ventilation and pressure-controlled ventilation modes in acute respiratory distress syndrome. An active test lung (ASL 5000™) connected to five intensive care unit ventilators was used in a model of acute respiratory distress syndrome. Respiratory muscle efforts (muscle pressure) were configured in three different ways: no effort (muscle pressure: 0cmH2O); inspiratory efforts only (muscle pressure:-5cmH2O, neural inspiratory time of 0.6s); and both inspiratory and expiratory muscle efforts (muscle pressure:-5/+5cmH2O). Volume-controlled and pressure-controlled ventilation modes were set to deliver a target tidal volume of 420mL and positive end-expiratory pressure of 10cmH2O. The tidal volume delivered to the lungs, alveolar pressures at the end of inspiration, and alveolar pressures at end expiration were evaluated. When triggered by the simulated patient, the median tidal volume was 27mL lower than the set tidal volume (range-63 to +79mL), and there was variation in alveolar pressures with a median of 25.4cmH2O (range 20.5 to 30cmH2O). In the simulated scenarios with both spontaneous inspiratory and expiratory muscle efforts and with a mandatory respiratory rate lower than the simulated patient's efforts, the median tidal volume was higher than controlled breathing. Adjusting respiratory muscle effort and pulmonary ventilator respiratory rate to a value above the patient's respiratory rate in assisted/controlled modes generated large variations in tidal volume and pulmonary pressures, while the controlled mode showed no variations in these outcomes.