13 Update in Intensive Care and Emergency Medicine Edited by J. L. Vincent
Pulmonary Function in Mechanically Ventilated Patients Edited by S.Benito and A. Net With 138 Figures and 25 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona
Series Editor Prof. Dr. Jean Louis Vincent Clinical Director, Department of Intensive Care, Erasme Hospital Free University of Brussels, Route de Lennik 808 1070 Brussels, Belgium Volume Editors Prof. Dr. Salvador Benito, Prof. Dr. Alvar Net Servei de Medicina Intensiva Hospital de la Santa Creu i Sant Pau Universitat Autonoma de Barcelona 08025 Barcelona, Spain Library of Congress Cataloging-in-Publication Data Pulmonary function in mechanically ventilated patients/edited by S. Benito and A. Net. (Update in intensive care and emergency medicine; 13) Includes index. ISBN-13: 978-3-540-52650-6 e-isbn-13: 978-3-642-84209-2 DOl: 10.1007/978-3-642-84209-2 I. Artificial respiration. 2. Pulmonary function tests. [I. Lung physiopathology. 2. Respiration, Artificial. 3. Ventilators. Mechanical.] I. Net, A. (Alvar) II. Benito, S. (Salvador) III. Series. [DNLM: WI UP66H v. 13/WF 102 P9825] RC87.9.P84 1990615.8'36- dc20 DNLM/DLC This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its current version, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1991 The use of registered names, trademarks, etc. in the publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by Macmillan India Ltd., Bangalore, India 19-3130-5 4 3 2 1 0 - Printed on acid-free paper
Foreword This welcome addition to the series Update in Intensive Care and Emergency Medicine emerges from the most recent of a series of meetings organized by Alvar Net and Salvador Benito of Barcelona. This gathering provided a forum for European intensive care specialists to exchange ideas, knowledge and experience on, the measurements feasible in mechanically ventilated patients. The scope was ambitious, ranging from basics like the measurement of airway pressure and blood gases to topics such as CT, MRI and the multiple inert gas elimination technique. The success of the meeting made publication a logical consequence. The book is unique in its breadth. The contributors, from numerous centers in Europe and North America, cover all techniques employed in intensive care units, describing indications, contraindications, procedures, biases and complications. This volume will be an invaluable source for intensive care specialists and other clinicians. Alongside practical descriptions of procedures they employ routinely (spirometry, measurement of systemic vascular oxygen pressure, Swan-Ganz catheterization, BOPA etc.), they will find accounts of such sophisticated techniques as online measurement offunctional residual capacity, isotope determination of ventilation/perfusion ratios, diaphragmatic metabolism and peripheral oxygen exchange. I am especially happy to see the book published by Springer-Verlag, which has distinguished itself in the field of intensive care medicine. Creteil, France, December 1990 F. Lemaire
Contents Introduction with Special Reference to Ventilator-associated Barotrauma (J. Milic-Emili, C. Tantucci, M. Chasse, and C. Corbeil).... 1 Pneumotachographic Recording of Ventilatory Pattern (J. Sanchis, J. L. Diez-Betoret, J. Canet, and P. Casan).... 9 Spirometry (P. Casan and J. Sanchis)................. 23 Inspiratory Occluded Airway Pressure (R. Fernandez).... 39 Transdiaphragmatic Pressure (L. Brochard) 52 Assessment of the Breathing Workload During Mechanical Ventilation (J. J. Marini)........... 62 Assessment of Diaphragmatic Function (M. Aubier)...... 81 Pulmonary Compliance (S. Benito)................... 86 Respiratory Impedance (D. Navajas, R. Farre, and M. Rotger)................. 99 Elastance and Resistance of Respiratory System (J. Milic-Emili)................................... 114 Respiratory Inductive Plethysmography (J. Dall'Ava-Santucci and A. Armanganidis)............. 121 Closing Volume (J. Ibanez and J. M. Raurich)... 143 Functional Residual Capacity in Acute Respiratory Failure. Methods of Measurement in the Ventilated Patients and Their Clinical Utility (J. Mancebo)... 155 FRC and Efficiency of Gas Mixing in the Lung. SF 6 (B. Jonson)...................................... 169
VIII Contents Determination of Lung-Ventilation and Perfusion by Isotope Technique (G. Hedenstierna and L. Tokics).... 174 Multiple Inert Gas Elimination Technique (R. Rodriguez-Raisin)... 183 Pulmonary Diffusion Capacity (H. Burchardi and T. Stokke)... 191 Blood Gases (J. M. Raurich and J. Ibanez).... 208 Pulse Oximetry in the Intensive Therapy Unit (c. D. Hanning and D. M. Lassey)... 221 Transcutaneous Monitoring of Oxygen and Carbon Dioxide (F. Clergue and E. Barre).... 234 Mixed Venous Oxygen Saturation Monitoring in Mechanically Ventilated Patients (J. L. Vincent).... 244 Capnography (Ll. Blanch)... 251 Measurement of Oxygen Consumption and Carbon Dioxide Production in Artificially Ventilated Patients (G. Annat, J. P. Viale, O. Bertrand, B. Delafosse, Y. Bouffard, and J. Motin)... 267 Bronchoalveolar Lavage (M. Antonelli, M. Bufi, and A. Gasparetto).............. 281 Measurement of Extrapulmonary Lung Water ( A. Net and C. Triginer)............................ 293 Interactions Between Convective and Diffusive Components of O 2 Transport to the Tissues (J. Roca, M. Hogan, and P. D. Wagner).... 304 Energy Metabolism and Diaphragmatic Function: Applications of Magnetic Resonance Spectroscopy (G. Gutierrez and F. Palizas).... 315 The Oxygen Consumption of the Respiratory Muscles (c. Roussos)... 328 Clinical Applications of Balloon Occlusion Pulmonary Angiography (BOPA) (G. Conti. J.-L. Tehoul. M. Rocco. and A. GasDaretto)..... 337
Contents IX Computerized Axial Tomography of the Lung During Acute Respiratory Failure (L. Gattinoni, M. Bambino, P. Pelosi, F. M eda, L. F agnoni, A. M areta, G. Avanzi, and A. Pesenti).. 345 Subject Index... 353
List of Contributors Annat, G. H6pital Edouard-Herriot, Universite 69437 Lyon Cedex 3, France Antonelli, M. Istituto di Anestesiologia e Rianimazione, PolicIinico Umberto I, Universita "La Sapienza", Viale del PolicIinico, 155,00161 Roma, Italy Armanganidis, A. Laboratoire d'explorations FonctionelIes, H6pital Universitaire Cochin, 27, rue du Faubourg St. Jacques, 75014 Paris Cedex 14, France Aubier, M. Clinique Pneumologique, H6pital Bichat Claude Bernard, Universite de Paris VII, 46, rue Henri-Huchard, 75877 Paris Cede x 18, France Avanzi, G. Barre, E. Groupe Hospitalier Pitie-Salpetriere, 83, blvd de I'Hopital, 75651 Paris Cedex 13, France Benito, S. de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, 08025 Barcelona, Spain Bertrand, o. Hopital Edouard-Herriot, Universite 69437 Lyon Cedex 3, France Blanch, Ll. de SabadelI, Parc Tauli, s/n., SabadelI, Spain Bombino, M. Bouffard, Y. H6pital Edouard-Herriot, Universite 69437 Lyon Cedex 3, France Brochard, L. Service de Reanimation Medicale, Hopital Henri Mondor, 51, ave du Marechal de Lattre de Tassigny, 94010 Creteil, France Bufi, M. Istituto di Anestesiologia e Rianimazione, PolicIinico Umberto I, Universita "La Sapienza", Viale del PolicIinico, 155, 00161, Roma, Italy Burchardi, H. Zentrum Anaesthesiologie, Georg August-Universitat, Robert-Koch-Strasse 40, 3400 Gottingen, West Germany
XII List of Contributors Canet, J. Servei d'anestesia i Reanimacii>, Hospital "Germans Trias i Pujol", Universitat Autonoma de Barcelona, Carr. de Can yet, sin., Badalona, Spain Casan, P. Unitat de Funcii> Pulmonar, HospItal de la Santa Creu i Sant Pau, Umversltat Autonoma de Barcelona, Av. St. Antoni M. Claret, 167,08025 Barcelona, Spain Chasse, M. Service de Pneumologie, Hopital Samt Luc, Universite de Montreal, Montreal, Quebec, Canada Clergue, F. Departement d' Anesthesie-Reammation, Groupe Hospitalier Pitie-Salpetru:re, 83, blvd de I'Hopital, 75651 Paris Cedex 13, France Conti, G. Istituto di Anestesiologia e Rianimazione, Policlinico Umberto I, Universita "La Sapienza",Viale del Policlinico, 155,00161 Roma, Italy Corbeil, C. Service de Pneumologle, Hopital Saint Luc, Universite de Montreal, Montreal, Quebec, Canada Dall'Ava-Santucci, J. Departement de Physiologie, Laboratoire d'explorations Fonctionelles, Hopital Universitaire Cochin, 27, rue du Faubourg St. Jacques, 75014 Paris Cedex 14, France Delafosse, B. Departement d' Anesthesle-Reanimation, Hopital Edouard-Herriot, Universite 69437 Lyon Cedex 3, France Diez-Betoret, J. L. Unitat de Funcii> Pulmonar, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Av. St. Antoni M. Claret, 167,08025 Barcelona, Spain Fagnoni, L. Farre, R. Laboratori de Biofisica i Bioenginyeria, Facultat de Medicina, Zona Universitaria de Pedralbes, Barcelona, Spain Fernandez, R. de Sabadell, Parc Tauli, sin., Sabadell, Spain Gasparetto, A. Istituto di Anestesiologia e Rianimazione, Policlinico Umberto I, Universita "La Sapienza", Viale del Policlinico, 155,00161 Roma, Italy Gattmoni, L. Gutierrez, G. Pulmonary Division, Intensive Care Division, University of Texas Health Science Center, 6431 Fannin, Suite 1. 274, Houston, TX 77030, USA Hanning, C. D. Department of Anaesthesia, The General Hospital, University of Leicester, Leicester, LE 54 PW, United Kingdom Hedenstierna, G. Institutionen for Klinisk Fysiologi, Uppsala Universitet, Akademiska Sjukhuset, 75185 Uppsala, Sweden Hogan, M. Section of Physiology, University of California San Diego, La Jolla, CA 92093, USA Ibanez, J. Son Dureta, Andrea Doria, 55, 07014 Palma de Mallorca, Spain
List of Contributors XIII Jonson, B. Institutionen for Klinisk Fysiologi, Lund Universitet, 221 85 Lund, Sweden Lassey, D. M. Department of Anaesthesia, Cleveland Hospital, Leicester, United Kingdom Mancebo, J. de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, 08025 Barcelona, Spain Marini, J. J. Pulmonary Critical Care, St. Paul Ramsey Medical Center, 640 Jackson Street, St. Paul, MN 155101-2591, USA Meda, F. Milic-Emili, J. Meakins-Christie Laboratories, Department of Physiology, McGill University, 3626 St. Urbain Street, Montreal, Quebec H2X 2P2, Canada Moreto, A. Motin, J. H6pital Edouard-Herriot, Universite 69437 Lyon Cedex 3, France Navajas, D. Laboratori de Biofisica i Bioenginyeria, Facultat de Medicina, Zona Universitaria de Pedralbes, Barcelona, Spain Net, A. de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, 08025 Barcelona, Spain Palizas. F. Division de Terapia Intensiva, Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires, Argentina Pelosi, P. DOlllzetti, 106, 20052 Monza (MI), Italy Pesenti, A. Raurich, J. M. Son Dureta, Andrea Doria, 55, 07014 Palma de Mallorca, Spain Roca, J. Servei de Pneumologia, Hospital Clinic i Provincial, VilJarroel, 170, 08036 Barcelona, Spain Rocco, M Istituto di Anestesiologia e Rianimazione, Polic1inico Umberto I, Universita "La Sapienza", Viale del Polic1inico, 155,00161 Roma, Italy Rodriguez-Roisin, R. Servei de Pneumologia, Hospital Clinic i Provincial, Villarroel, 170, 08036 Barcelona, Spain Rotger, M. Laboratori de Biofisica i Bioenginyeria, Facultat de Medicina, Zona Universitaria de Pedralbes, Barcelona, Spain Roussos, C. Critical Care Department, Evangelismos Hospital, 45-47 Ipsilandou Str., 11521 Athens, Greece Sanchis, J. Unitat de Funcio Pulmonar, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Av. St. Antoni M. Claret, 167,08025 Barcelona, Spain
XIV List of Contributors Stokke, T. Ylliviei Hospital, University of Oslo, Oslo, Norway Tantucci, C. Service de Pneumologie, Hopltal Saint Luc, Universite de Montreal, Montreal, Quebec, Canada Teboul, J.-L. Service de Reanimation Medicale, Hopital Bicetre, Le Kremlin-Bicetre, France Tokics, L. Klinikt Fisiologiska Institutionen, Huddinge Sjukhus Karolinska Institutet, Huddinge, Sweden Triginer, C. Unitat de Vigilancia Intensiva, Hospital de Traumatologia de la Vall d'hebr6n, Universitat Autonoma de Barcelona, Barcelona, Spain Viale, J. P. Hospital Edouard-Herriot, Universite 69437 Lyon Cede x 3, France Vincent, J. L. Departement Soins Intensifs, Hopital Erasme, Universite Libre de Bruxelles, Route de Lennik 808, 1070 Bruxelles, Belgium Wagner, P. D. Section of Physiology, University of California San Diego, La Jolla, CA 92093, USA