title: Potential inadequacy of automatic tube compensation to decrease inspiratory work load after at least 48 hours of endotracheal tube use in the clinical setting.
abstract: BACKGROUND
  Endotracheal tubes (ETTs) impose a substantial respiratory work load on mechanically ventilated patients. Automatic tube compensation (ATC) should overcome this flow-dependent resistive work load; however, ETT resistance can be increased by tracheal secretions or ETT deformities.  Our bench study investigated whether ATC provides effective respiratory work load relief in used ETTs.
  
  
  METHODS
  We enrolled 20 critically ill patients requiring mechanical ventilation for longer than 48 hours. After extubation, we collected the used ETTs and measured the pressure-time products  (PTPs) by using a bellows-in-a-box lung model that simulated spontaneous breathing, at a respiratory rate of 10 breaths/min, inspiratory time of 1.0 s, and tidal volumes (V(T)) of 300 mL, 500 mL, and 700 mL. The ventilator was set at ATC 100% with PEEP of 5 cm H(2)O and F(IO(2))  of 0.21. The flow and airway pressure at the proximal (P(aw)) and distal (P(tr)) ends of the ETT were recorded, and the PTP integrated from P(tr) analyzed.
  
  
  RESULTS
  PTP values increased with V(T) during ATC. Even at 100% ATC the ventilator did not completely  compensate for the PTP imposed by the ETT. In used ETTs, peak flow and peak P(aw) were lower and PTP values were greater than in new ETTs. As V(T) increased, the percentage difference in the PTP values between the new and used ETTs increased.
  
  
  CONCLUSIONS
  ATC does not necessarily  compensate for an ETT-imposed respiratory work load. ETT configuration changes and tracheal secretions can increase ETT resistance and decrease the ability of ATC to compensate for the increased respiratory work load.
authors.affiliation: Department of Emergency and Critical Care Medicine, The University of Tokushima Graduate School, Tokushima City, Japan. joto@clin.med.tokushima-u.ac.jp
authors.forename: Jun
authors.initials: J
authors.lastname: Oto
authors.forename: Hideaki
authors.initials: H
authors.lastname: Imanaka
authors.forename: Emiko
authors.initials: E
authors.lastname: Nakataki
authors.forename: Rie
authors.initials: R
authors.lastname: Ono
authors.forename: Masaji
authors.initials: M
authors.lastname: Nishimura
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000403:Airway Resistance / Q000502:physiology*; D016638:Critical Illness; D019544:Equipment Failure Analysis; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation*; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D011175:Positive-Pressure Respiration / Q000295:instrumentation*; D012131:Respiratory Insufficiency / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy*; D013990:Tidal Volume / Q000502:physiology; D013997:Time Factors; D014939:Work of Breathing / Q000502:physiology*; D055815:Young Adult