Intracycle power distribution in a heterogeneous multi-compartmental mathematical model: possible links to strain and VILI

The effect of inspiratory rise time on mechanical power calculations in pressure control ventilation: dynamic approach

BACKGROUND

Mechanical power may serve as a valuable parameter for predicting ventilation-induced injury in mechanically ventilated patients. Over time, several equations have been developed to calculate power in both volume control ventilation (VCV) and pressure control ventilation (PCV). Among these equations, the linear model mechanical power equation (MPLM) closely approximates the reference method when applied in PCV. The dynamic mechanical power equation (MPdyn) computes power by utilizing the ventilatory work of breathing parameter (WOBv), which is automatically measured by the mechanical ventilator. In our study, conducted in patients with Covid-19 Acute Respiratory Distress Syndrome (C-ARDS), we calculated mechanical power using both the MPLM and MPdyn equations, employing different inspiratory rise times (Tslope) at intervals of 5%, ranging from 5 to 20% and compared the obtained results.

RESULTS

In our analysis, we used univariate linear regression at both I:E ratios of 1:2 and 1:1, considering all Tslope values. These analyses revealed that the MPdyn and MPLM equations exhibited strong correlations, with R2 values exceeding 0.96. Furthermore, our Bland-Altman analysis, which compared the power values derived from the MPdyn and MPLM equations for patient averages and all measurements, revealed a mean difference of -0.42 ± 0.41 J/min (equivalent to 2.6% ± 2.3%, p < 0.0001) and -0.39 ± 0.57 J/min (equivalent to 3.6% ± 3.5%, p < 0.0001), respectively. While there was a statistically significant difference between the equations in both absolute value and relative proportion, this difference was not considered clinically relevant. Additionally, we observed that each 5% increase in Tslope time corresponded to a decrease in mechanical power values by approximately 1 J/min.

CONCLUSIONS

The differences between mechanical power values calculated using the MPdyn and MPLM equations at various Tslope durations were determined to lack clinical significance. Consequently, for practical and continuous mechanical power estimation in Pressure-Controlled Ventilation (PCV) mode, the MPdyn equation presents itself as a viable option. It is important to note that as Tslope times increased, the calculated mechanical power exhibited a clinically relevant decrease.

Optimized ventilation power to avoid VILI

The effort to minimize VILI risk must be multi-pronged. The need to adequately ventilate, a key determinant of hazardous power, is reduced by judicious permissive hypercapnia, reduction of innate oxygen demand, and by prone body positioning that promotes both efficient pulmonary gas exchange and homogenous distributions of local stress. Modifiable ventilator-related determinants of lung protection include reductions of tidal volume, plateau pressure, driving pressure, PEEP, inspiratory flow amplitude and profile (using longer inspiration to expiration ratios), and ventilation frequency. Underappreciated conditional cofactors of importance to modulate the impact of local specific power may include lower vascular pressures and blood flows. Employed together, these measures modulate ventilation power with the intent to avoid VILI while achieving clinically acceptable targets for pulmonary gas exchange.

Practical assessment of risk of VILI from ventilating power: a conceptual model

At the bedside, assessing the risk of ventilator-induced lung injury (VILI) requires parameters readily measured by the clinician. For this purpose, driving pressure (DP) and end-inspiratory static 'plateau' pressure ([Formula: see text]) of the tidal cycle are unquestionably useful but lack key information relating to associated volume changes and cumulative strain. 'Mechanical power', a clinical term which incorporates all dissipated ('non-elastic') and conserved ('elastic') energy components of inflation, has drawn considerable interest as a comprehensive 'umbrella' variable that accounts for the influence of ventilating frequency per minute as well as the energy cost per tidal cycle. Yet, like the raw values of DP and [Formula: see text], the absolute levels of energy and power by themselves may not carry sufficiently precise information to guide safe ventilatory practice. In previous work we introduced the concept of 'damaging energy per cycle'. Here we describe how-if only in concept-the bedside clinician might gauge the theoretical hazard of delivered energy using easily observed static circuit pressures ([Formula: see text] and positive end expiratory pressure) and an estimate of the maximally tolerated (threshold) non-dissipated ('elastic') airway pressure that reflects the pressure component applied to the alveolar tissues. Because its core inputs are already in use and familiar in daily practice, the simplified mathematical model we propose here for damaging energy and power may promote deeper comprehension of the key factors in play to improve lung protective ventilation.