Tracheal pressure regulated volume assist ventilation in acute respiratory failure

Purpose: Proportional assist ventilation (PAV) uses volume assist (VAV) and flow assist ventilation (FAV) to reduce elastic and resistive effort, respectively. Proportional assist ventilation may be difficult to apply clinically, particularly due to FAV related considerations. It was hypothesized that regulating tracheal (Ptr) rather than airway opening pressure (Pao), to overcome endotracheal tube related resistive effort, during VAV would provide an effective alternative method of ventilation. We therefore compared the effects of Pao and Ptr regulated VAV on breathing pattern and inspiratory effort. Methods: In seven intubated patients, flow, volume, Pao, Ptr, esophageal and transdiaphragmatic pressure were measured during VAV (0-80% respiratory system elastance) using Pao vs Ptr to regulate ventilator applied pressure. Breathing pattern and the pressure-time integral of the inspiratory muscles (∫P_mus·dt) and diaphragm (∫P_di·dt) were determined. Results: Compared to spontaneous breathing, the respiratory rate to tidal volume ratio, or rapid shallow breathing index (RSBI), improved progressively with increasing VAV (130 ± 64 vs 70 ± 35, VAV 0 vs 80%; P < 0.05) while inspiratory effort fell (∫P_mus·dt = 39.6 ± 7.5 vs 28.5 ± 7.2 cm H₂O·sec·L^-1, ∫P_di·dt, = 35.4 ± 7.8 vs 24.2 ± 5.9 cm H₂O·sec·L^-1, VAV 0 vs 80%; P < 0.05) due to a decrease in elastic related effort. At any given level of support, there was further reduction in RSBI, ∫P_mus·dt, and ∫P_di·dt (which averaged 23.6 ± 2.7, 33.7 ± 44, and 38.5 ± 5.1%, respectively; P < 0.05) for Ptr compared to Pao regulated VAV due to a decrease in resistive effort. Conclusions: Tracheal pressure regulated VAV can be a simple and effective method of partial ventilatory support in acute respiratory failure. Further work will be needed to determine its efficacy and potential benefit relative to PAV and other modes of ventilation in routine clinical practice.