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Maintenance of Airway Pressure During Filter Exchange Due to Auto-Triggering

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Maintenance of Airway Pressure During Filter Exchange Due to Auto-Triggering Maintenance of Airway Pressure During Filter Exchange Due to Auto-Triggering Joakim Engstro¨m MSc CCRN, Henrik Reinius MD, Camilla Fro¨jd PhD CCRN, Hans Jonsson MSc CCRN, Go¨ran Hedenstierna MD PhD, and Anders Larsson MD PhD BACKGROUND: Daily routine ventilator-filter exchange interrupts the integrity of the ventilator circuit. We hypothesized that this might reduce positive airway pressure in mechanically ventilated ICU patients, inducing alveolar collapse and causing impaired oxygenation and compliance of the respiratory system. METHODS: We studied 40 consecutive ICU subjects (P /F ratio < 300 mm aO2 IO2 Hg), mechanically ventilated with pressure-regulated volume control or pressure support and > PEEP 5cmH2O. Before the filter exchange, (baseline) tidal volume, breathing frequency, end-inspiratory plateau pressure, and PEEP were recorded. Compliance of the respiratory system was calculated; F , blood pressure, and pulse rate were registered; and P ,P , pH, and base IO2 aO2 aCO2 excess were measured. Measurements were repeated 15 and 60 min after the filter exchange. In addition, a bench test was performed with a precision test lung with similar compliance and ؎ resistance as in the clinical study. RESULTS: The exchange of the filter took 3.5 ؎ 1.2 s (mean SD). There was no significant change in P (89 ؎ 16 mm Hg at baseline vs 86 ؎ 16 mm Hg at 15 aO2 or in compliance of the respiratory system (41 ؎ 11 (24. ؍ min and 88 ؎ 18 mm Hg at 60 min, P ؍ ؎ ؎ mL/cm H2O at baseline vs 40 12 mL/cm H2O at 15 min and 40 12 mL/cm H2O at 60 min, P .32). The bench study showed that auto-triggering by the ventilator when disconnecting from the expiratory circuit kept the tracheal pressure above PEEP for at least 3 s with pressure controlled ventilation. CONCLUSIONS: This study showed that a short disconnection of the expiratory ven- tilator circuit from the ventilator during filter exchange was not associated with any significant deterioration in lung function 15 and 60 min later. This result may be explained by auto-triggering of the ventilator with high inspiratory flows during the filter exchange, maintaining airway pres- sure. (ISRCTN.org registration ISRCTN76631800.) Key words: acute lung injury; positive-pressure respiration; positive end-expiratory pressure; air filters; intensive care units. [Respir Care 2014;59(8):1210–1217. © 2014 Daedalus Enterprises] Introduction with lungs prone to atelectasis, eg, in ARDS.1,2 It has been found in experimental ARDS models that lung collapse PEEP is used to prevent alveolar de-recruitment and occurs within seconds after discontinuation of positive air- maintain oxygenation in mechanically ventilated patients way pressure.3 In fact, Neumann et al3 showed that the time constant for development of a major collapse was 0.6 s. It is well known that oxygenation deteriorates when the endotracheal tube is disconnected from the ventilator Mr Engstro¨m, Dr Reinius, Dr Fro¨jd, Mr Jonsson, and Dr Larsson are circuit in mechanically ventilated ICU patients, particu- affiliated with Anesthesiology and Intensive Care, Department of Surgi- cal Sciences, Uppsala University; Dr Hedenstierna is affiliated with the Department of Medical Sciences, Uppsala University, Uppsala, Sweden. This research was supported by the Swedish Heart-Lung Foundation, by Correspondence: Joakim Engstro¨m MSc CCRN, Department of Surgical Swedish Research Council Uppsala county grant 5315, and by an insti- Sciences, Uppsala University, SE-751 85 Uppsala, Sweden. E-mail: tutional grant from the Department of Surgical Sciences, Anesthesiology [email protected]. and Intensive Care, Uppsala University. The authors have disclosed no conflicts of interest. DOI: 10.4187/respcare.02892 1210 RESPIRATORY CARE • AUGUST 2014 VOL 59 NO 8 MAINTENANCE OF AIRWAY PRESSURE DURING FILTER EXCHANGE larly in connection with endotracheal suctioning.4-6 More- over, the sole removal of positive airway pressure causes QUICK LOOK 5,7 a marked decrease in lung volume. In our ICU, we rou- Current knowledge tinely exchange ventilator filters every 24 h for hygienic Breathing circuit filters in the expiratory limb of the reasons, in accordance with the recommendations by the ventilator circuit protect ventilator components from manufacturer.8 These filters are placed between the expi- moisture and contamination. Daily routine changes of ratory limb of the ventilatory tubing and the ventilator. breathing circuit filters are recommended to prevent Because this procedure breaks the integrity of the venti- increased expiratory resistance and untoward events. latory circuit, we hypothesized that this could compromise Changing the filter requires breaking the circuit, loss of lung function, something that is not recognized or dis- airway pressure, and the potential for lung de-recruit- cussed either in the clinic or in studies of different venti- ment. latory strategies. Therefore, the aim of this study was to assess whether the daily routine exchange of ventilator What this paper contributes to our knowledge filters would lead to deterioration of oxygenation or com- pliance of the respiratory system in mechanically venti- In a group of mechanically ventilated patients with hy- lated ICU patients. To further explore the mechanisms, we poxemia, a short disconnection of the expiratory ven- assessed the airway pressure change proximal to the tip of tilator circuit during filter exchange was not associated the endotracheal tube in a bench test after a simulated filter with any significant deterioration in lung function. This exchange. may be explained by auto-triggering of the ventilator with high inspiratory flow, maintaining airway pressure. Methods The study was divided into 2 parts: (1) a clinical study in 40 mechanically ventilated subjects (Fig. 1) and (2) a bench test using different ventilatory modes to estimate tracheostomy tube (Shiley Evac tracheostomy tube cuffed the pressure change distal to the endotracheal tube at a system, Covidien, Mansfield, Ohio) was recorded, as well simulated ventilator filter exchange (Fig. 2). as whether a heat-moisture exchanger (HME, Pharma Sys- tems, Knivsta, Sweden) or an active humidifier (RT430, The Clinical Study Fisher & Paykel Healthcare, Auckland, New Zealand) was used. The study was performed in Anesthesiology and Inten- Before the exchange of the high-efficiency particulate sive Care, Department of Surgical Sciences, Uppsala Uni- air filter (Servo Duo Gard, Maquet), placed between the versity, Uppsala, Sweden. The study was approved by the expiratory limb of the ventilatory circuit and the ventilator, university ethics committee (ISRCTN.org registration tidal volume, breathing frequency, end-inspiratory plateau ISRCTN76631800). Informed consent was obtained from pressure (EIP), and PEEP were recorded (baseline). In the the subjects’ next of kin before inclusion. subjects with controlled ventilation without any subject- Mechanically ventilated subjects were included consec- triggered breaths (n ϭ 32), compliance was calculated as utively if: P /F ratio was Յ 300 mm Hg, PEEP was tidal volume/(EIP Ϫ PEEP). Both EIP and PEEP were aO2 IO2 Ն 5cmHO, patient had an arterial cannula, patient was measured after a prolonged pause of 10 s. F , arterial 2 IO2 Ն 18 y, and patient was not pregnant. blood pressure, and pulse rate were recorded, and arterial blood was sampled for determination of P ,P , pH, aO2 aCO2 Protocol and base excess (ABL800 Flex, Radiometer, Brondby, Denmark). The subjects were mechanically ventilated with pres- The subject remained connected to the ventilator during sure-regulated volume control (PRVC), pressure controlled the whole filter exchange procedure. The expiratory tubing ventilation, or pressure support ventilation using a Servo-i was disconnected from the old filter, which was then re- ventilator (Maquet, Wayne, New Jersey). Flow triggering moved from the ventilator inlet and exchanged, and the was used and set at 1 L/min in all subjects. The inspiratory expiratory tubing was reconnected to the new filter. Mea- rise time was set at 5%. The ventilator tubing circuit set surements were repeated 15 and 60 min after the filter (A4VXXXXX, Vital Signs, Totowa, New Jersey) had an exchange. In addition, the duration of the exchange pro- inner diameter of 22 mm and was 275 cm in length cedure was recorded. Finally, in 4 subjects, airway pres- (137.5 cm inspiratory and 137.5 cm expiratory limb). The sure (Paw) was measured in the Y-piece connected to the size of the endotracheal tube (ETT) (Portex Blue Line ETT and 1 cm below the ETT tip via a 15 cm, 16 gauge Sacett, Smiths Medical, Hythe, Kent, United Kingdom) or catheter (Arrow, Limerick, Pennsylvania). Endotracheal RESPIRATORY CARE • AUGUST 2014 VOL 59 NO 8 1211 MAINTENANCE OF AIRWAY PRESSURE DURING FILTER EXCHANGE Disconnection Baseline 15 min 60 min Arterial blood gas, CRS Arterial blood gas, CRS Arterial blood gas, CRS Hemodynamics Hemodynamics Hemodynamics Fig. 1. Outline of the study. The arrows above the horizontal line indicate interventions, whereas the arrows below the line indicate ϭ measurements. CRS compliance of the respiratory system. Table 1. Subject Characteristics Pressure pod Test lung Subject Characteristics (N ϭ 40) Values Age (y) 64 Ϯ 15 Female sex (n, %) 12 (30) SAPS III 67 Ϯ 14 Duration of mechanical ventilation (d) 8.6 Ϯ 9.9 ICU stay (d) 10 Ϯ 11 P 1 cm aw Hospital stay (d) 31 Ϯ 38 below ETT ICU mortality (n, %) 5 (13) tip Tubing 30-d mortality (n, %) 9 (23) circuit ARDS Mild (n, %) 13 (32.5) HEPA Moderate (n, %) 25 (62.5) filter Severe (n, %) 2 (5) Mechanical ventilation settings Tidal volume (mL/kg) 7.2 Ϯ 1.6 Breathing frequency (breaths/min) 12 Ϯ 5 Ϯ FIO2 0.5 0.1 Ϯ EIP (cm H2O) 24 5 Ϯ PEEP (cm H2O) 12 4 Ventilator Gas exchange Fig. 2. Experimental setup of the bench test. The high-efficiency Arterial pH 7.39 Ϯ 0.07 Ϯ particulate air filter was placed in the expiratory limb of ventilator. PaCO2 (mm Hg) 45 14 P ϭ airway pressure.
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