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WordPress Shortcode. Occlusion of the expiratory valve. The calculation of iPEEP in a spontaneously breathing patient is much more complex and difficult to extend to clinical practice, due to the frequent contribution of the respiratory muscles during active expiration.
Through the determination of esophageal pressure Pesoph , an approximation can be obtained via the negative inflexion of Pesoph immediately before activating the trigger in each inspiration.
The existence of hyperinsufflation is suspected, since inspiration begins before the expiratory flow returns to zero. The value calculated by this procedure is usually lower than that confirmed from sustained expiration on detecting the lowest iPEEP value, while the second yields the mean value.
There is general agreement that in order to minimize the risk of volutrauma and barotrauma, Pplateau must be kept below 30mmHg.
The attempts to exceed iPEEP constitute one of the main causes of respiratory failure in COPD exacerbation, and moreover represent a major cause of failure in the weaning of patients with airflow obstruction.
However, ePEEP should not be applied to patients with COPD while under controlled ventilatory modes with the purpose of maximizing exhalation and of preventing regional overdistension—reserving it for when the assisted mode is resumed, to thus reduce the patient triggering effort.
Taking into account the waterfall principle, equaling ePEEP to iPEEP would imply a maximum decrease in inspiratory effort without the risk of hyperinsufflation. If the above were not enough, there is still another problem: iPEEP varies in relation to the respiratory parameters respiratory frequency and ventilation , the position of the patient, and the changes in respiratory mechanics related to the course of the disease and treatment response.
Therefore, the values of iPEEP measured under controlled ventilation in a relaxed patient may be very different from those calculated under spontaneous ventilation—the situation in which we wish to apply ePEEP.
In clinical practice it is useful to ask the patient about his or her degree of comfort and dyspnea while we very gradually increase ePEEP, so that the patient is personally aware of the relief in effort as a result of counterbalancing of the iPEEP until hyperinflation increases the dyspnea will be proportional to Vei, as a result of which the patient can notice the increase in hyperinsufflation.
The concept of cardiopulmonary interaction is intimately linked to that of dynamic hyperinsufflation, since the lungs, heart and pulmonary circulation are located in the same compartment chest cavity , with the consequence changes in cardiac function as a result of the variations in intrapleural pressure.
Hypotension is the most common effect of diminished preload, and is accentuated by hypovolemia. In this context, situations of electromechanical dissociation have been described 34 ; as a result, if hyperinsufflation is suspected in a patient subjected to mechanical ventilation, it is advisable to disconnect the respirator for 20—30s.
Because of the increase in right ventricular post-loading, hyperinsufflation can give rise to acute failure with dilatation of the right ventricle — causing displacement of the interventricular septum and reduction of left ventricle filling, due to the interdependence between both ventricles.
The intrathoracic pressure is partially transmitted to the circulation, and therefore influences the measured values of central venous pressure and wedge pressure—a fact that must be taken into account in hemodynamic monitoring. Prospective studies 35 have shown the application of protocols to accelerate the process without increasing the failure rate. It is therefore advisable to start weaning as soon as possible, particularly in COPD.
In order to assess the adequate moment for starting the process, due consideration is required of the possible causes of respirator dependency and of difficulties during weaning Table 3 , as well as of the factors allowing us to predict successful weaning Table 4.
Particularly in COPD and in difficult situations, the use of noninvasive mechanical ventilation is recommended after extubation, with a view to avoid the need for reintubation. Causes of respirator dependency and obstacles in weaning. Gas exchange.