title: Effects of continuous, expiratory, reverse, and bi-directional tracheal gas insufflation in conjunction with a flow relief valve on delivered tidal volume, total positive end-expiratory pressure, and carbon dioxide elimination: a bench study.
abstract: BACKGROUND
  Tracheal gas insufflation (TGI) can increase total positive end-expiratory pressure (total-PEEP) when flow is delivered in a forward direction, necessitating adjustments to maintain total-PEEP constant. When TGI is delivered throughout the respiratory cycle, additional adjustments are needed to maintain tidal volume (V(T)) constant.
  
  
  OBJECTIVE
  Determine if bi-directional TGI (bi-TGI) (simultaneous flows toward the lungs and upper airway) in combination with a flow relief valve eliminates the increase in total-PEEP and maintains a constant V(T), thus simplifying TGI administration.
  
  
  METHODS
  Using an artificial lung model and pressure control ventilation, we studied the effect of TGI at 10 L/min on inspired V(T), total-PEEP, and CO(2) elimination during 6 conditions: (1) control (no TGI, no catheter in the airway), (2) baseline (catheter in the airway but no TGI), (3) continuous TGI, (4) expiratory TGI, (5) reverse TGI, and (6) bi-TGI. Each condition was studied under 3 inspiration-expiration ratios (1:1, 1:2, and 2:1). A preset flow relief valve was inserted into the ventilator circuit during all TGI conditions with continuous flow.
  
  
  METHODS
  University research laboratory.
  
  
  RESULTS
  CO(2) elimination efficiency was similar under all conditions. Total-PEEP increased with continuous TGI and expiratory TGI, decreased during reverse TGI, and was unchanged during bi-TGI. With the flow relief valve in place, and no adjustment in mechanical ventilation, the change in minute ventilation ranged from 0% to 10%, with the least change during bi-TGI (0-5%). During bi-TGI, gas flow was equivalent in both directions during dynamic conditions and the flow relief valve consistently removed gas at 10 L/min under various pressures.
  
  
  CONCLUSIONS
  Our data from an artificial lung model support that continuous bi-TGI minimizes the change in total-PEEP seen during other TGI modalities. The flow relief valve compensated for the extra gas volume delivered by the TGI catheter, thereby eliminating the need to make ventilator adjustments. Used in combination with a flow relief valve, bi-TGI appears to offer unique advantages by providing a simpler method to deliver TGI. Further testing is indicated to determine if similar benefits occur in the clinical setting.
authors.affiliation: Respiratory Care Department, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA. delgadoe@msx.upmc.edu.
authors.forename: E
authors.initials: E
authors.lastname: Delgado
authors.forename: B
authors.initials: B
authors.lastname: Hete
authors.forename: L A
authors.initials: LA
authors.lastname: Hoffman
authors.forename: F J
authors.initials: FJ
authors.lastname: Tasota
authors.forename: M R
authors.initials: MR
authors.lastname: Pinsky
mesh_terms: D000403:Airway Resistance; D000818:Animals; D001944:Breath Tests; D002245:Carbon Dioxide / Q000032:analysis*; D006801:Humans; D007327:Insufflation / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D008168:Lung / Q000502:physiology*; D008953:Models, Anatomic; D010102:Oxygen Inhalation Therapy / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D011175:Positive-Pressure Respiration / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D015656:Respiratory Mechanics; D012815:Signal Processing, Computer-Assisted; D013990:Tidal Volume; D014132:Trachea
chemical_list: D002245:Carbon Dioxide